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AMERICAN 
PRACTICE  OF  SURGERY 


A  COMPLETE  SYSTEM  OF  THE  SCIENCE  AND 
ART  OF  SURGERY,  BY  REPRESENTATIVE  SUR- 
GEONS OF  THE  UNITED  STATES  AND  CANADA 


JOSEPH  D.  BRYANT,  M.D. 
ALBERT   H.  BUCK,  M.D. 


OF    NEW    YOKK    CITY 


COMPLETE    IIT    EIGHT    VOLUMES 


profusely  miustrateb 


VOLUME    ONE 


NEW   YORK 
WILLIAM   WOOD   AND   COMPANY 

MDCCCCVI  • 


COPYEKiHT,    1906, 

BY   WILLIAM    WOOD    AND   COMPANY. 


I 


W 

^ 


El 


PREFACE. 

jIHE  portrayal  of  surgery  as  it  is  practised  to-day  in  the 
United  States  and  Canada  can  be  best  accomplished,  we 
think,  by  the  co-operation  of  a  number  of  surgeons  who 
have  gained  eminence  in  the  particular  sphere  of  activity  which 
they  are  invited  to  describe.  A  careful  study  of  the  problem  which 
we,  as  editors,  were  called  upon  to  solve  led  us  to  the  conclusion 
that  such  a  composite  work  would  present  a  picture  more  true  to 
life  and  one  more  perfect  in  detail  if  the  different  writers  were  not 
confined  within  boundary  lines  too  strictly  drawn.  While  this 
course  would  almost  necessarily  involve  a  certain  amount  of  repeti- 
tion, we  believed  this  redundance  to  be  counterbalanced  by  the  fact 
that  the  sum  total  of  information  supplied  could  not  fail  to  be 
greater  than  if  the  plan  of  closer  restriction  were  to  be  adopted  ;  for 
experience  has  shown  that  no  xwo  writers  are  likely  to  treat  a 
subject  in  precisely  the  same  manner  or  to  furnish  exactly  the 
same  set  of  details  even  in  important  matters. 

The  first  one  of  the  eight  volumes  of  which  this  treatise  is 
to  be  composed  is  herewith  submitted  to  the  consideration  of  the 
Profession,  and  we  sincerely  trust  that  this  product  of  the  com- 
bined labor  of  all  concerned  will  command  the  respect  and  con- 
fidence of  those  who  consult  its  pages. 

The  Editors. 


CONTRIBUTORS  TO  VOLUME  I. 


LEONARD    WOOLSEY    BACON,  Jr., 
M.D.,  New  Haven,  Conn. 
Instructor  in  Operative  Surgery,  Medical  De- 
partment, Yale  University. 

JOSEPH    COLT   BLOODGOOD,  M.D.. 

Baltimore,  Md. 

Associate  Professor  of  Surgery,  Johns  Hop- 
kins University;  Associate  in  Surgery,  Johns 
Hopkins  Hospital. 

HARLOW    BROOKS,  M.D.,  New  York, 

N.  Y. 

Assistant  Professor  of  Pathology,  University 
and  Bellevue  Hospital  Medical  College;  Pa- 
thologist to  Montefiore  Hospital  and  to  St. 
Vincent's  Hospital;  Visiting  Physician  to  City 
Hospital. 

JOSEPH  D.  BRYANT,  M.D.,  New  York, 

N.Y. 

Professor  of  the  Principles  and  Practice  of 
Surgery  and  of  Operative  and  Clinical  Sur- 
gery, University  and  Belle\TJe  Hospital  Medi- 
cal College  ;  Visiting  Surgeon,  Bellevue  and  St. 
Vincent's  Hospitals;  Consulting  Surgeon,  Hos- 
pital for  Ruptured  and  Crippled,  Woman's 
Hospital,  and  Manhattan  State  Hospital  for  the 
Insane. 


WALTER    J.  DODD,  Boston,  Mass. 

Director  of  -Y-Ray  Laboratory  of  the  Massa- 
chusetts General  Hospital. 

HARVEY  R.  GAYLORD.  M.D..  Buflfalo, 
N.  Y. 

Professor  of  Surgical  Pathology,  Medical  De- 
partment, University  of  Buffalo,  N.  Y.;  Attend- 
ing Surgeon,  Erie  County  Hospital;  Assistant 
Surgeon,  Buffalo  General  Hospital. 

PRESTON    M.  HICKEY.   M.D.,  Detroit, 
Mich. 

Professor  of  Radiography,  Detroit  Post-Gradu- 
ate School  of  Medicine;  Professor  of  Pathol- 
ogy, Detroit  College  of  Medicine;  Radiog- 
rapher to  Children's  Free  Hospital. 


THEODORE       A,      McGRAW,     M.D., 
LL.D.,  Detroit,  Mich. 
Professor  of  Surgery,  Detroit  College  of  Medi- 
cine; Attending  Surgeon,  St.  Mary's  Hospital; 
Consulting  Surgeon,  Harper's  Hospital. 

JAMES   E.  MOORE,  M.D.,  Minneapolis, 
Minn. 

Professor  of  Surgery,  Medical  Department, 
University  of  Minnesota  ;  Surgeon-in-Chief, 
Northwestern  Hospital. 

ALBERT   GEORGE  NICHOLLS,  M.D.. 
CM.,  Montreal,  Can. 

Assistant  Professor  of  Pathology  and  Bacteri- 
ology, McGill  University,  Montreal;  Assistant 
Physician  to  the  Montreal  General  Hospital; 
Pathologist  to  the  Western  General  Hospital, 
Montreal. 

EDWARD     HALL     NICHOLS,     M.D., 

Boston,  Mass. 

Assistant  Professor  of  Surgical  Pathology,  Har- 
vard Aledical  School;  Assistant  Visiting  Sur- 
geon, the  Boston  City  Hospital. 

ROBERT   B.   OSGOOD,  M.D.,  Boston, 
Mass. 

Assistant  Orthopedic  Surgeon,  ^lassachusetts 
General  Hospital ;  formerly  Skiagrapher  to  the 
Children's  Hospital,  Boston. 

PAUL      MONROE      PILCHER,   M.D., 

Brooklyn,  N.  Y. 

Assistant  Surgeon,  Methodist  Episcopal  Hospi- 
tal, Brooklyn. 

STEPHEN  SMITH,  M.D.,  LLD..   New 

York,  N.  Y. 

Formerly  Professor  of  Anatomy  and   Clinical 

Surgery,  Belle\nie    Hospital  JNIedical   College: 

Consulting  Surgeon,  Bellevue.  St.  Vincent's,  and 

Columbus  Hospitals ;    President.  State  Board  of 

Charities. 

ALDRED    SCOTT   WARTHIN,   Ph.D., 
M.D.,  Ann  Arbor.  Mich. 
Professor   of   Pathology   and   Director    of   the 
Pathological  Laboratory.  University  of  Michi- 
gan, Ann  Arbor,  Mich. 


CONTENTS. 

Preface,  ........ 

Introduction:  Evolution  of  American  Surgery, 


PART  I. 

SURGICAL   PATHOLOGY. 
Inflammation,    ...........  71 

The  Nature  and  Significance  of  the  Various  Disturbances  of  Nu- 
trition Observed  in  Connection  with  Surgical  Diseases  and 
Conditions,        ...........     146 

Processes  of  Repair,  .........  256 

Tumors  and  Tumor  Formation,  .......  291 

Theories  of  Tumor  Formation,  .......  370 

Parasitical  Relations  of  Cancer,  .......  387 


PART  II. 

COMPLICATIONS  AND   SEQUELS. 

Infections  which  Sometimes  Occur  in  Various  Surgical  Diseases  and 
Conditions,        ...........     415 

Surgical  Shock,       .        .         .         .         .         .         .         .         .         .         .     4'63 

PART  III. 

GENERAL  SURGICAL  DIAGNOSIS. 
General  Principles  of  Surgical  Diagnosis,  .....     501 

The  Body  Fluids  in  General  Surgical  Disease,  with  Special  Reference 

to  Their  Diagnostic  Value,    ........     555 

The  Epiphyses  and  Their  Radiographic  Interpretation,      .         .  578 

The  Technique  of  Radiographic  Work  as  Applied  to  Surgery,  and  the 
Interpretation  of  Radiographs,  ......     599 

PART  IV. 

GENERAL  SURGICAL  TREATMENT. 

General  Principles  of  Surgical  Treatment,  and  the  Various  Proced- 
ures, Instruments,  etc.,  that  Facilitate  the  Application  of  These 
Principles,        ...........     691 


PART  V. 

GENERAL  SURGICAL  PROGNOSIS. 

General  Prognosis  in  Surgical  Diseases  and  Conditions, 
Index,       .   .      .    '     . 


771 
799 


INTRODUCTION. 


INTRODUCTION. 


THE    EVOLUTION    OF   AMERICAN 
SURGERY. 

By  STEPHEN  SMITH,  M.D.,  LL.D.,  New  York  City. 

The  American  Practice  of  Surgery  has  had  three  distinct  periods  of  de- 
velopment, each  of  wliich  was  characterized  by  conditions  sufficiently  marked  to 
constitute  an  era  in  the  history  of  its  evolution. 

The  first  period  extended  from  the  settlement  of  the  country  to  the  organiza- 
tion of  medical  schools — 1765-67— and  may  be  called  the  primitive  era.  During 
this  period  there  were  but  few  surgeons  who  had  been  qualified  to  practise  by  a 
systematic  course  of  education,  for  to  obtain  such  an  education  required  an  at- 
tendance upon  foreign  schools,  and  few  students  of  that  time  had  the  means 
necessary  for  such  an  undertaking.  To  meet  existing  conditions  the  future 
practitioner  was  compelled  to  become  an  apprentice  to  a  practising  physician, 
and  "read  mecUcine  and  surgery"  in  his  office.  His  surgical  text-book  consisted 
of  a  copy  of  Bromfield,  Gooch,  White,  Pott,  or  any  other  reputable  author  of 
that  day,  and  his  diploma,  at  the  expiration  of  his  apprenticeship,  was  the  cer- 
tificate of  his  master  that  he  had  served  the  appointed  time.  There  were  a  few 
notable  instances  of  surgeons,  in  the  later  years  of  that  period,  who  had  graduated 
from  foreign  schools,  whose  practice  was  of  a  high  order  for  that  time.  But  their 
practice  was  along  the  lines  taught  in  the  schools  of  London  and  Edinburgh. 

The  second  period  extended  from  the  establishment  of  medical  schools  in 
this  country  to  the  introduction  of  anffisthesia  and  antiseptics  into  surgical  prac- 
tice— 1846-72 — and  may  be  called  the  formative  era.  During  this  period  the 
foundations  of  a  distinctly  American  practice  of  surgery  were  laid  by  the  or- 
ganization of  medical  schools,  in  which  the  future  practitioners  of  surgery  in  this 
country  were  to  obtain  a  competent  education. 

Two  discoveries  were  made  during  this  period  which  revolutionized  the 
practice  of  surgery — anaesthesia  and  antisepsis.  The  first  abolished  pain  as  a 
disturbing  element  during  operative  procedures,  and  the  second  prevented  sup- 
puration during  the  healing  process ;  together  they  effected  a  painless  operation 

3 


4  AMERICAN  PRACTICE  OF  SURGERY. 

and  healing  of  the  wound  by  first  intention — results  hitherto  sought  m  vain  by 
the  elder  surgeons.  These  discoveries  swept  away  the  long-established  metes 
and  bounds  of  the  field  of  operative  surgery,  and  made  it  as  limitless  as  are  the 
diseases  and  injuries  of  the  hmnan  body  and  man's  desire  and  efforts  to  relieve 
them. 

The  third  period,  which  is  now  passing,  may  be  called  the  practical  era.  The 
surgeons  of  to-day  are  makmg  the  history  of  this  era,  and  hi  this  work  they 
will  record  its  marvellous  progress  for  a  quarter  of  a  century,  and  illustrate 
with  historical  accuracy  the  intricate  procedures,  the  instruments  of  precision, 
and  the  vast  variety  of  ingenious  apparatus  and  appliances  with  which  they 
accomplish  results  which  in  the  second  period  would  have  been  regarded  as 
miraculous. 

It  will  be  the  scope  and  purpose  of  this  introductory  paper  to  review  those 
conditions  of  the  formative,  or  pioneer,  period  which  gave  to  the  American  prac- 
tice of  surgery  whatever  national  traits  and  peculiarities  have  characterized  its 
evolution.  It  will  be  our  aim  in  this  exposition  to  trace  the  origin  and  develop- 
ment of  the  scientific  spirit  which  inspired  and  controlled  the  pioneer  surgeons 
of  that  period,  rather  than  to  record  the  notable  achievements  of  individuals, 
with  names  and  dates  in  due  succession,  which  have  only  a  chronological  inter- 
est. We  shall  not  attempt,  therefore,  to  follow  the  precise  historical  order  of 
'  subjects,  but  shall  endeavor  to  secure  that  continuity  of  thought,  on  the  part  of 
the  student,  essential  to  a  just  appreciation  of  the  genius  of  American  surgery. 
The  detailed  history  of  American  medicine  and  surgery  has  been  amply  written 
by  competent  authorities,  and  can  be  readily  consulted  by  those  seeking  specific 
information  as  to  names,  dates,  or  events. 

Two  questions  arise  at  the  outset  of  this  review  which  it  is  important  to  de- 
termine, in  order  that  no  injustice  may  be  done  to  any  one  who  may  claim  rec- 
ognition in  our  narrative,  either  to  the  distinction  of  being  a  discoverer,  or  to 
honors  due  to  a  surgeon.  These  questions  are:  First,  Who  is  a  discoverer?  sec- 
ond, Who  is  a  surgeon? 

The  definition  of  a  discoverer  was  long  since  made  by  the  Rev.  Sidney  Smith, 
as  follows:  "That  man  is  not  the  first  discoverer  of  any  art  who  first  says  the 
thing,  but  he  who  says  it  so  long,  so  loud,  and  so  clearly  that  he  compels  man- 
kind to  hear  him."  The  same  opinion  is  happily  expressed  by  Prof.  Howard  A. 
Kelly,  of  Johns  Hopkins  Hospital,  viz. :  "  Any  claim  to  priority  in  medicine  and 
surgery  always  rests,  by  consent  of  the  profession,  not  upon  the  date  of  perform- 
ance, but  upon  the  date  of  publication."  He  very  pertinent!}'  adds :  " Reflection 
will  only  confirm  this  dictum  by  showing  that  the  printed  word  is,  after  all,  the 
only  possible  arbiter  which  can  be  appealed  to  when  disputes  arise." 

The  definition  of  an  American  surgeon,  which  will  correctly  apply  to  a  given 
specified  class  of  practitioners  during  the  past  century  and  a  half,  would  seem 
to  include  the  entire  profession,  for  circumstances  compelled  every  physician, 


INTRODUCTION.  5 

especially  during  the  early  part  of  this  period,  to  perform  the  duties  of  a  surgeon. 
But  there  has  always  been  a  class  of  practitioners  who  have  devoted  themselves, 
by  preference,  to  the  practice  of  surgery  and  have  been  recognized  as  surgeons. 
The  definition  of  surgeon  which  is  best  adapted  to  the  purposes  of  this  work 
was  made  by  Dr.  Valentine  Mott,  one  of  the  highest  authorities  on  this  subject 
to  whom  we  can  refer,  who  says :  "  We  regard  those  as  surgeons,  and  those  alone, 
who  have,  by  conscientious  devotion  to  the  study  of  our  science  and  the  daily 
habitual  discharge  of  its  multifarious  duties,  acquired  that  laiowledge  which 
renders  the  mind  of  the  practitioner  serene,  his  judgment  sound,  and  hands  skil- 
ful, while  it  holds  out  to  the  patient  rational  hopes  of  amended  health  and  pro- 
longed life." 

The  evolution  of  American  surgery  began  with  the  first  organized  efforts  to 
give  the  medical  students  of  this  coimtry  systematic  instruction  for  the  purpose 
of  fully  qualifying  them  for  practice — 1765-67.  Whatever  other  influences  may 
contribute  to  the  formation  of  the  special  peculiarities  of  the  practice  of  a  profes- 
sion, it  is  the  education  of  its  individual  members  which  determines,  more  largely 
than  any  other  factor,  its  individuality.  The  school  formulates  the  principles 
which  govern  the  future  acts  of  its  pupils.  But  the  quality  and  value  of  the  in- 
struction of  the  school  depends  entirely  upon  the  qualifications  of  the  teachers. 
Before  we  can  properly  estimate  the  practice  of  the  Amei'ican  surgeon,  therefore, 
we  must  inquire  as  to  his  educational  qualifications  and  then  as  to  the  condi- 
tions under  which  he  performed  his  professional  duties. 

American  surgery  had  its  origin  in  the  medical  schools  of  London  and  Edin- 
burgh. Prior  to  the  organization  and  establishment  of  medical  colleges  in 
this  country,  the  graduated  surgeons  took  their  degrees  from  the  British 
schools.  And  during  the  succeeding  half  century  the  more  ambitious  students 
of  surgery  who  graduated  from  the  home  schools  took  post-graduate  courses  of 
instruction  in  the  schools  and  hospitals  of  the  mother  country.  A  reference  to 
the  teachers  of  the  science  and  art  of  surgery  in  the  British  schools  during  this 
period  enables  us  to  form  a  just  estimate  of  the  qualifications  of  their  American 
graduates  to  create  an  adequate  system  of  medical  education  in  this  country. 

In  London  we  recognize  Percival  Pott  (1713-88),  John  Hmiter  (1728-93), 
Everard  Home  (1763-1832),  John  Abernethy  (1764-1831),  Astley  Paston  Cooper 
(1768-1841)  as  teachers  and  writers  of  their  times  who  exerted  the  greatest 
power  over  the  progress  of  scientific  surgery.  To  these  more  prominent  names 
should  be  added  the  names  of  William  Blizard  (1743-1835),  Henry  Cline  (1750- 
1827),  Charles  Bell  (1778-1842),  Benjamin  Collins  Brodie  (1783-1862),  Ben- 
jamin Travers  (1783-1858).  Of  these  teachers  the  one  Avhose  genius  more  com- 
pletely dominated  all  others  was  John  Hunter,  the  most  conspicuous  figure  in 
the  annals  of  modern  surgery.  Many  American  students  placed  themselves 
under  the  immediate  instruction  of  this  great  master,  and  their  subsequent 
achievements  attest  the  value  of  his  teachings  and  example.    As  surgeon  in  the 


6  AilERICAX  PRACTICE  OF  SURGERY. 

British  army  in  tire  Spanish  Peninsula,  1761-63,  he  had  acquired  valuable 
knowledge  of  military  surger}-,  which  he  imparted  to  his  pupils  and  which  they 
utilized  in  our  colonial  wars. 

In  the  Edinburgh  school  the  Monroes — father,  son,  and  grandson — ruled 
supreme  from  1725  to  1846,  a  period  of  one  hundred  and  twenty-one  years.  The 
elder  ]Monroe  was  a  pupil  of  Cheselden  and  was  the  first  professor  of  anatomy  in 
the  University  of  Edinbm'gh ;  he  gave  clinical  lectmes  on  siu-ger}*,  was  a  writer 
of  much  distinction,  and  took  rank  as  an  authority  on  manj'  subjects.  His  son 
was  professor  of  sm-gery  imtil  1810,  when  he  was  succeeded  by  his  son,  who  re- 
tained the  position  until  1846.  Of  the  Monroes,  the  elder  was  the  most  eminent 
as  a  teacher  and  surgeon,  and  by  his  reputation  gave  more  character  to  the 
university  school  than  his  son  or  grandson.  For  more  than  a  centmy  and 
a  hah  Edinburgh  was  regarded  as  a  great  centre  of  medical  education,  and  few 
American  medical  students  who  went  abroad  to  complete  their  education  failed 
to  attend  and  graduate  at  the  universitJ^ 

Scarcelj'  less  attractive  to  students  who  visited  Edinburgh  dming  the  years 
1790  to  1800  was  the  private  school  for  anatomy,  surgery,  and  obstetrics  of 
John  and  Charles  Bell.  Jolm  Bell  was  a  bold  and  fearless  surgeon,  a  brilliant 
operator,  a  vigorous  writer,  and  a  caustic  critic.  His  school  was  conducted  in  op- 
position to  the  University  JMedical  College,  and  the  two  most  prominent  profes- 
sors of  the  latter — Alexander  Mom-oe  and  Benjamin  Bell — were  the  subjects  of 
the  most  imsparing  criticism  on  the  part  of  the  founder  of  the  new  school. 
Charles  Bell  was  eminent  as  an  artist,  writer,  and  teacher,  and  for  several  j'ears 
the  school  was  the  favorite  resort  of  the  more  advanced  medical  students,  espe- 
ciall}'  those  American  ^^sitors  who  were  devoting  themselves  to  surgery. 

But  few  American  students,  comparatively,  visited  the  schools  and  hospitals 
of  Paris,  except  incidentally  in  their  travels.  Before  1750  Jean  Louis  Petit  was 
for  a  long  period  the  most  eminent  surgeon  of  Paris,  and  it  was  his  genius 
which  gave  direction  to  French  sm'gery.  Le  Dran  and  Le  Cat  (1700-68),  con- 
temporaries of  Petit,  were  active  in  hospital  work,  and  later,  in  the  eighteenth 
and  the  beginning  of  the  nineteenth  centurj^,  the  more  emment  teachers  of 
surgerj-  in  the  Paris  hospitals  were  Desault  (1730-95),  Sabatier  (1732-1811), 
Deschamps  (1740-1824),  and  manj^  others  of  less  note. 

Mr.  Erichsen,  in  his  address  on  "Impressions  of  American  Surgery,"  truth- 
fully remarks :  "  The  method  of  doing  things  in  surgery  is  transmitted  directly 
from  the  master  to  the  pupil;  the  American  sui'geon  of  a  past  generation  ac- 
quired in  this  way  the  traditionary  art  of  British  surgerj-,  and  has  transmitted 
it  dh'ectly  to  his  descendants.  Surgeons  of  both  nations  drew  then-  inspiration 
from  the  same  source  and  drank  at  the  same  fomitain  of  knowledge."  Though 
American  surgery  was  originally  but  a  transplanted  root  of  British  surgery  and 
its  subsequent  evolution  has  been  along  the  inlierited  lines  established  by  the 
parent,  it  is  not  difficult  to  distinguish,  at  many  points  of  contrast,  that  the 


INTRODUCTION.  7 

American  practice  of  surgery  has  always  been  characterized  by  a  freedom  of 
thought,  a  promptness  of  action,  and  an  affluence  of  resources  quite  unusual  in 
British  practice.  Foreign  surgeons,  accustomed  to  the  observance  of  technical 
rules  of  practice,  attributed  the  independent  spirit  of  American  surgeons  in 
their  methods  of  operating  to  ignorance  of  the  established  rules,  or  to  mere  reck- 
lessness. But  experience  has  proved  that  the  American  practice  of  surgery, 
from  the  earliest  periods,  has  illustrated  the  genius  of  British  surgery,  suddenly 
emancipated  from  the  thraldom  with  which  the  traditions  of  the  barber  sur- 
geons fettered  the  progress  of  scientific  surgery  in  Europe  during  the  eighteenth 
and  the  early  years  of  the  nineteenth  century. 

It  should  be  premised  that,  at  the  period  of  the  organization  of  medical 
schools  in  this  country,  surgery  had  not  assumed  the  position  of  a  science  and 
an  art  in  the  medical  schools  of  the  capitals  of  Europe.  As  a  branch  of  medical 
instruction  it  was  subordinated  to  that  of  medicine,  and  little  else  was  taught 
than  bandaging  and  the  method  of  performing  the  few  recognized  operations. 
Wliatever  didactic  surgical  teaching  was  given  was  in  connection  with  other 
branches,  especially  anatomy,  and  often  with  midwifery.  The  more  prominent 
surgeons  in  the  centres  of  medical  education  in  Europe  were  struggling  to  give 
an  independent  position  to  surgery  in  the  curriculum  of  the  schools,  but  the  op- 
position of  the  ruling  authorities  was  overpowering  during  the  eighteenth  and 
far  into  the  nineteenth  century.  And  this  opposition  to  a  separate  chair  or  pro- 
fessorship of  surgery  was  especially  dominant  in  the  Edinburgh  school,  from 
which  so  many  American  medical  students  graduated.  Educated  as  were  most 
of  the  founders  of  our  first  medical  colleges  in  the  traditions  of  that  school,  it  is 
not  surprising  that,  with  a  single  exception,  they  began  to  build  on  similar  foun- 
dations. That  exception  was  the  Medical  Department  of  King's  College,  New 
York. 

In  1765  the  Medical  Department  of  the  College  of  Philadelphia  was  formally 
organized,  chiefly  through  the  efforts  of  Dr.  John  Morgan  and  Dr.  William  Ship- 
pen,  Jr.  They  were  natives  of  Philadelphia  and  graduates  of  literary  institu- 
tions. They  studied  medicine  in  due  course  in  the  offices  of  prominent  physi- 
cians, the  former  with  Dr.  Redman,  and  the  latter  with  his  father,  and  completed 
their  professional  education  in  the  British  schools.  Dr.  Shippen  began  to  give 
lectures  on  anatomy  in  1762,  and  annually  repeated  the  course  until  1765,  when 
the  Medical  Department  of  the  College  of  Philadelphia  was  organized.  In  the 
scheme  of  instruction  the  promoters  of  the  school  followed  the  European  plan  of 
giving  surgery  a  subordinate  place  in  connection  with  other  branches,  and 
united  it  with  anatomy.  Dr.  Joseph  Carson,  historian  of  the  Medical  Depart- 
ment of  the  University  of  Pennsylvania,  says:  "The  medical  school  of  Phila- 
delphia may  be  said  to  be  the  legitimate  offspring  of  that  of  Edinburgh." 

Dr.  Shippen,  though  not  a  surgeon,  but  devoted  to  the  practice  of  midwifery, 
was  appointed  professor  of  anatomy  and  surgery,  and  held  this  position  imtil 


8  AMERICAN  PRACTICE  OF  SURGERY. 

1805,  a  period  of  forty  years.  It  appears,  from  the  announcement  of  his  lectures, 
that  the  instruction  m  surgery  was  hmited  to  "all  the  necessary  operations  of 
surgery"  and  "a  course  of  bandages."  Considering  how  few  operations  were 
regarded  as  necessary  and  how  important  was  the  use  of  the  bandage,  we  can 
estimate  the  character  of  the  surgical  instruction  imparted  at  that  time.  Dr. 
Shippen  was  a  popular  teacher,  and  by  his  devotion  to  the  duties  of  his-  profes- 
sorship, amid  the  distractions  caused  by  the  war  of  the  Revolution,  and  the  dis- 
sensions of  the  profession,  powerfully  aided  in  preserving  the  founda,tions  on 
which  the  Medical  Department  of  the  University  of  Pennsylvania,  the  successor 
of  the  College  of  Philadelphia,  had  been  reared. 

In  1767,  the  Medical  Department  of  King's  College,  New  York,  was  organized, 
and  on  the  2d  day  of  November  of  that  year  the  introductory  address  to  the  first 
course  of  lectures  was  given.    In  the  plan  of  instruc- 
tion in  surgery  adopted  by  the   promoters  of  this 
school,  we  recognize  the  first  departure  from  Euro- 
pean methods  and  the  initial  step  in  creating  a  class  of 
distinctly  American  siu-geons.    The  faculty  not  only 
exhibited  a  commendable  spirit  of  independence  of 
the  traditions  of  the  past,  but  they  demonstrated  un- 
equivocally that  they  recognized  higher  ideals  of  sur- 
gery as  a  science  and  an  art  than  were  prevalent  La 
foreign  countries.    Under  the  leadership  of  Dr.  John 
Jones,  surgery  was  divorced  from  all  other  branches 
of  a  medical  education  and  erected  into  an  indepen- 
FiG  1  —John  Jones  (1729-      ^^^^^  professorship.   Dr.  Jones  was  appointed  full  pro- 
fessor of  surgery,  the  first  appointment  of  the  kind 
in  this  country,  and  gave  the  first  lecture  on  the  ninth  day  of  November,  1767. 
He  gave  an  annual  course  of  lectures  until  the  college  was  closed  by  the  war  of 
the  Revolution,  1775. 

John  Jones  (1729-91)  was  of  Welsh  origin.  His  grandfather,  Dr.  Edward  Jones, 
was  from  Wales,  and  came  to  this  country  in  the  famous  ship  Welcoine,  with  William 
Penn  and  his  colony.  He  married  a  daughter  of  Dr.  Thomas  Wynne,  Speaker  of 
the  Assembly  of  Penn's  colony.  His  son,  Dr.  Evan  Jones,  settled  at  Jamaica,  Long 
Island,  N.  Y.,  where  John  Jones  was  born  in  1729.  He  was  educated  at  a  private 
school  in  New  York,  and,  at  the  age  of  eighteen  j^ears,  began  the  study  of  medicine 
with  Dr.  Thomas  Cadwalader,  of  Philadelphia.  He  visited  London  and  attended 
the  lectures  of  Dr.  William  Hunter  and  the  practice  of  Mr.  Percival  Pott,  in  St. 
Bartholomew's  Hospital.  In  1757,  he  again  visited  France  and  obtained  the  degree 
of  Doctor  in  Jledicine  from  the  University  of  Rheims.  In  Paris  he  attended  the 
anatomical  lectures  of  Petit,  and  received  instruction  from  Le  Dran  and  Le  Cat, 
in  Hotel  Dieu. 

Dr.  Jones  began  the  practice  of  surgery  in  the  city  of  New  York  in  175.3,  and 
acquired  a  wide  reputation  for  skill  and  success.    He  performed  the  first  operation 


INTRODUCTION.  9 

of  lithotomy,  and  subsequently  was  so  successful  in  this  field  of  practice  that  he  was 
not  only  extensively  employed  in  the  treatment  of  calculus  of  the  urinary  bladder, 
but,  according  to  Mease,  his  success  was  so  great  that  the  operation  of  Uthotomj^, 
which  had  fallen  into  disrepute  in  other  States,  owing  to  the  failures  of  operators, 
was  rendered  popular. 

Dr.  Jones  enlisted  as  surgeon  in  the  Continental  Army,  but  soon  retired  on  ac- 
count of  ill-health.  In  1780  he  removed  to  Philadelphia,  became  surgeon  to  the 
Pennsylvania  Hospital,  and  was  the  professional  attendant,  on  occasions,  of  Wash- 
ington and  Frankhn.    He  died  on  June  23d,  1791,  at  the  age  of  sixty-three. 

Dr.  Jones  was  eminently  qualified  to  be  the  founder  of  a  system  of  surgical 
education.  The  qualities  of  his  mind  fitted  him  to  be  a  teacher,  and  his  standard 
of  professional  qualification  was  ideal.  He  was  devoted  to  surgery  as  a  science 
and  an  art,  and  cultivated  it  with  passionate  zeal.  He  travelled  extensively  and 
availed  himself  of  every  opportunity  to  acquire  knowledge.  Although  he  made 
specialties  of  anatomy  and  surgery,  his  general  studies  took  a  wide  range  and 
his  inquiries  extended  to  the  collateral  sciences.  He  made  warm  friends  of  the 
most  prominent  surgeons  of  that  time  in  the  hospitals  abroad,  and  was  a  favorite 
student  of  Pott,  of  St.  Bartholomew's  Hospital,  London,  and  of  Petit  and  Le 
Dran,  of  Hotel  Dieu,  Paris.  He  attended  the  lectures  of  Dr.  William  Hunter, 
and  must  have  been  brought  into  more  or  less  intimate  association  with  his 
brother,  John  Hunter,  who  was  nearly  the  age  of  Dr.  Jones  and  had  just  com- 
pleted his  studies,  1752.  But  he  probably  derived  no  other  benefit  from  such 
association  than  perhaps  a  more  intense  devotion  to  his  professional  studies. 

Dr.  Beck,  in  his  "Historical  Sketch,"  remarks  of  Dr.  Jones:  "He  was  well 
fitted  by  education  and  his  various  accomplishments  to  become  the  instructor 
of  others";  and  adds:  "Not  merely  as  the  skilful  operator,  but  as  the  scientific 
surgeon  and  the  first  teacher  of  surgery  in  the  colonies,  he  justly  deserves  to  be 
styled  the  Father  of  American  Surgery." 

Dr.  Mease,  his  student  and  biographer,  thus  speaks  of  Dr.  Jones's  qualifica- 
tions as  a  teacher  of  surgery :  "  Viewing  the  science  in  an  enlarged  and  honorable 
light  as  comprehending  the  most  extensive  view  of  our  nature,  and  as  tending  to 
the  alleviation  and  abridgment  of  human  misery,  he  taught  his  pupils  to  despise 
the  servile  conduct  of  those  who  consider  the  profession  as  worthy  of  cultivation 
only  in  proportion  to  the  emoluments  which  it  yields,  and  to  rely  upon  the  solid- 
ity of  their  own  endowments  as  the  best  security  of  general  esteem  and  for  the 
acquisition  of  business." 

He  taught  the  twofold  nature  of  surgery — first,  as  a  science;  second,  as  an 
art — and  urged  his  students  to  become  medical  as  well  as  operative  surgeons. 
In  the  following  statement  he  formulated  his  opinion  of  the  true  surgeon :  "  Be- 
sides a  competent  acquaintance  with  the  learned  languages,  which  are  to  lay  the 
foundation  of  every  other  acquisition,  he  must  possess  an  accurate  knowledge 
of  the  structure  of  the  human  body,  acquired  not  only  by  attending  anatomical 


10 


AMERICAN  PRACTICE  OF  SURGERY. 


lectures,  but  by  frequent  dissections  of  dead  bodies  with  his  own  hands.  This 
practice  cannot  be  too  warmly  recommended  to  the  students  of  surgery.  It  is 
from  this  source,  and  a  knowledge  m  hydraulics,  they  must  derive  any  adequate 
notions  of  the  animal  economy  or  physiologJ^  .  .  .  There  must  be  a  happiness, 
as  well  as  art,  to  complete  the  character  of  the  great  surgeon.  He  ought  to  have 
firm,  steady  hands,  and  be  able  to  use  both  alike;  a  strong,  clear  sight;  and, 
above  all,  a  mind  calm  and  intrepid,  3'et  humane  and  compassionate,  avoiding 
every  appearance  of  terror  and  cruelt}^  to  his  patients,  amid  the  most  severe 
operations." 

He  made  the  following  distinctions  between  the  qualified  and  imqualified 
surgeon:  "Whoever  has  acquired  just  and  general  ideas  of  the  natm'e  of  a  dis- 
ease will  seldom  be  at  a  loss  how  to  apply  them  on  particular  occasions;  and,  to 
him  who  wants  those  ideas,  no.  rules  or  directions  will  be  of  liiuch  consequence." 
He  concluded  his  introductory  lecture  as  follows:  "As  to  those  gentlemen 
who  will  neither  read  nor  reason,  but  practise  at  a  venture,  and  sport  with  the 
lives  and  limbs  of  their  fellow-creatures,  I  can  only,  with  Dr.  Huxliam,  advise 
them  seriously  to  peruse  the  sixth  commandment,  which  is,  'Thou  shalt  not 
kill.'" 

Immediately  on  the  close  of  the  war  the  third  pioneer  medical  school  was 
organized.     This  was  the  Medical  Department  of  Harvard  College,  Cambridge, 

Mass.,  established  in  1782.  The  plan  adopted 
was  that  of  the  foreign  schools,  anatomy  and 
surgery  being  imited  in  the  same  professorship. 
Dr.  John  Warren,  who  was  the  chief  promoter 
of  the  school  and  whose  lectures  on  anatomy 
before  the  students  of  Harvard  had  attracted 
much  public  attention,  was  appointed  the  pro- 
fessor of  anatomy  and  surgery. 

John  Warren  (1753-1815)  was  born  in  Rox- 
bury,  Mass.,  on  the  27th  of  July,  1753.  He  was 
a  younger  brother  of  Gen.  Joseph  Wan-en,  a  sirr- 
geon,  who  fell  at  the  battle  of  Bunker  Hill,  June 
17th,  1776.  He  was  educated  at  Harvard  Col- 
lege, which  he  entered  at  the  age  of  fourteen.  He 
then  began  the  study  of  medicine  with  his  brother, 
and  on  receiving  his  degree  he  located  in  Salem  at  the  age  of  twenty  years.  Like  his 
elder  brother,  Joseph,  Dr.  John  Warren  was  an  ardent  patriot,  and  joined  Colonel 
Pickering's  regiment  as  a  volunteer,  and  marched  to  the  defence  of  the  military 
stores  at  Concord.  He  was  present  at  the  first  iDattle  at  Lexington.  He  was  after- 
ward attached  to  the  main  army  under  the  immediate  command  of  General  Wash- 
ington. He  was  at  many  important  battles,  as  that  on  Long  Island,  at  Princeton, 
and  his  services  were  highly  appreciated  by  the  Commander-in-Chief.  After  suffer- 
ing a  severe  attack  of  fever,  he  was  assigned  to  dutv  at  Boston,  where  he  remained 


Fig.  2.— John  Warren  (1753-1815). 


INTRODUCTION.  11 

until  the  close  of  the  war.  In  1780  Dr.  Warren  gave  a  course  of  lectures  with  dis- 
sections at  the  MiUtary  Hospital,  and  in  the  following  year  they  were  more  public 
and  the  students  of  Harvard  College  were  permitted  to  attend.  These  lectures  led  to 
the  establishment  of  the  Medical  Department  of  Harvard,  the  first  course  of  lectures 
being  given  in  1783.  Dr.  Warren  occupied  the  chair  of  anatomy  and  surgery  for 
\apward  of  thirty  years.  He  died  April  3d,  1815,  of  ossification  of  the  valves  of  the 
heart  and  of  the  aorta,  from  the  sjmiptoms  of  which  he  had  long  suffered. 

Dr.  Thacher,  a  pupil  of  Dr.  Warren,  thus  describes  his  personal  appearance : 
■"  He  was  of  about  middling  stature  and  well  formed ;  his  deportment  was  agree- 
able ;  his  manners,  formed  in  a  military  school  and  polished  by  intercourse  with 
the  officers  of  the  French  army,  were  those  of  an  accomplished  gentleman.  An 
elevated  forehead,  black  eyes,  aquiline  nose,  and  hair  turned  up  from  his  fore- 
head gave  him  an  air  of  dignity  which  became  a  person  of  his  profession  and 
character." 

Of  Dr.  Warren's  qualifications  to  be  a  pioneer  in  establishing  a  system  of 
■surgical  education,  we  have  ample  evidence.  Dr.  James  Jackson,  an  excellent 
authority,  says:  "Dr.  Warren's  mental  attributes  were  of  a  high  order.  .  .  . 
His  reasoning  faculties  were  acute  and  powerful.  ...  He  possessed  a  peculiar 
tact  for  the  accurate  observation  of  disease  and  in  rapidly  arriving  at  conclu- 
sions. The  rapidity  of  his  bodily  movements  was  equally  remarkable.  .  .  .  His 
intellectual  activity  and  celerity  of  motion  were  manifested  in  all  of  the  habits 
of  his  life." 

During  the  latter  years  of  the  eighteenth  and  the  early  years  of  the  nine- 
teenth centuries,  these  pioneer  schools  underwent  many  changes  in  their  plans 
■of  organization.  The  Medical  Department  of  the  College  of  Philadelphia 
became  the  Medical  Department  of  the  University  of  Pennsylvania  in  1791; 
the  Medical  Department  of  King's  College  became  the  Medical  Department  of 
Columbia  College  in  1784,  and,  finally,  the  College  of  Physicians  and  Surgeons 
in  1810. 

But  a  more  important  event  in  the  history  of  these  schools  than  their 
plans  of  organization  was  impending.  A  new  era  was  dawning  which  was 
■destined  to  unpart  to  the  mstruction  in  surgery  a  scientific  spirit  hitherto 
tmknown.  This  department  was  no  longer  to  occupy  a  subordinate  position 
and  be  taught  in  connection  with  anatomy,  chemistry,  midwifery,  or  some 
other  branch,  but  was  to  be  the  subject  of  an  independent  professorship, 
as  in  the  original  organization  of  the  Medical  Department  of  King's  College, 
New  York. 

This  change  in  the  system  of  surgical  education  was  due  to  the  genius  of  John 
Hunter,  whose  researches  in  the  latter  half  of  the  eighteenth  century  gave  to 
surgery  the  character,  dignity,  and  responsibility  of  a  true  science.  While  the 
teachings  of  the  British  scientist  made  slow  progress  in  the  schools  of  Europe, 
on  account  of  national  prejudices  and  jealousies,  they  early  took  deep  and  abid- 


12  AMERIC.IX  PRACTICE  OF  SURGERY. 

ingroot  in  the  virgin  and  fertile  soil  which  the  young  and  plastic  medical 
schools  of  America  afforded,  and  thj-ough  which  they  were  to  mould  the 
character  of  its  future  surgeons.  It  was  a  fortmiate  circumstance  that  a 
corps  of  American  students  appeared  at  this  critical  period  in  the  history  of 
surgery  in  this  country,  thoroughly  qualified  by  temperament  and  education  ta 
become  the  propagators  of  the  principles  and  practice  of  the  new  faith  through 
these  pioneer  schools- 

The  first  American  surgeon,  familiar  with  Hunter's  doctrines,  who  became. a 
professor  of  surgery  in  this  country  was  Dr.  Wright  Post,  of  New  York. 

Wright  Post  (1766-1S2S)  was  born  at  Hempstead.  Queens  County,  N.  Y.,  Feb- 
ruary 19th.  1766.     He  was  educated  by  Daniel   Bayle}^,  a  teacher  in  that  locality. 
At  the  -age  of  fifteen  he  entered  the  office  of  Dr. 
Richard  Bayley,  a  prominent  surgeon  of  New  York, 
as  a  student  of  medicine.      In  17S4,  at  the  age  of 
mneteen,  he  went  to  London  and  became  the  house 
pupil  of  ^Mr.  Sheldon.    He  became  thorouglily  famil- 
iar ■nith   the   teachings  of   Hunter,  and  was  un- 
doubtedly there  when  that  surgeon  performed  his 
first   operation  of  ligating  the  femoral  arterj-  for 
aneurism,  1785.     In  1786  he  retmned  to  New  York 
and  gave  lectures  on  anatomy.      In  1792  he  was 
appointed  professor  of  surgerj-  in  the  jMedical  De- 
partment  of  Columbia,    formerly   King's   College. 
From  1796  to  1807,  when  the  CoUege  of  Phj'sicians 
Fig.  3.— Wright  Post  (1766-1S2S).       ^^^d  Surgeons  was  Organized,  Dr.  Post  taught  anat- 
omy and  surgery,  apparently  without  a  rival,  in 
Columbia  College.  ■    He  was  the  first  professor  of  anatomy  and  siugery  in  the  College 
of  Physicians  and  Surgeons,  but  in  1811  the  chair  was  cfi\'ided,  at  his  special  solici- 
tation,  and  he  retained  the  chair  of  anatomy,  teaching  surgerj'  only  clinically. 
In  1813  he  received  the  honorarj'  degree  of  Doctor  in  Medicine  from  the  regents  of 
the  I'mversity  of  New  York,  and  in  1821  was  elected  to  the  office  of  president  of  the 
College  of  Physicians  and  Surgeons,  a  position  which  he  held  until  1826,  when  he 
resigned.    He  died  in  1828,  at  the  age  of  sixty-two. 

For  upward  of  f ortj'  years  he  was  a  prominent  figure  in  the  medical  schools 
and  haspitals  of  New  York,  in  the  former  giving  didactic  and  in  the  latter  clin- 
ical instruction.  In  his  lectm-es  he  taught  surgerj-  as  a  true  science,  and  m  his 
practice  he  demonstrated  it  as  a  high  art.  He  was  also  the  legitimate  and 
worthy  successor  of  Dr.  John  Jones,  being  appointed  to  the  chair  of  surgery  in 
the  reorganized  iledical  Department  of  Columbia  College,  formerly  King's  Col- 
lege, in  1792. 

Dr.  Valentine  Mott,  one  of  his  most  devoted  pupils  and  eminently  qualified 
to  give  a  judicial  opmion,  thus  characterizes  Dr.  Post's  qualifications  as  a  teacher 
and  practitioner  of  surgery:  "He  was  unrivalled  as  an  anatomist,  a  most  beau- 
tiful dissector,  and  one  of  the  most  luminous  and  perspicuous  teachers  I  have 


INTRODUCTION. 


13 


ever  listened  to,  either  at  home  or  abroad.  His  manners  were  grave  and  digni- 
fied; he  seldom  smiled,  and  never  trifled  with  the  serious  and  responsible  duties 
in  which  he  was  engaged,  and  which  no  man  ever  more  solemnly  respected.  His 
delivery  was  precise,  slow,  and  clear — qualities  inestimable  in  a  teacher — and 
peculiarly  adapting  his  instructions  to  the  advancement  of  the  jvmior  portion  of 
the  class.  As  an  operator  he  was  careful,  slow,  and  elegant,  and  competent  to 
any  emergency  contemplated  by  the  then  existing  state  of  surgical  science." 

In  1811,  the  College  of  Physicians  and  Surgeons,  the  successor  of  the  Medical 
Department  of  Columbia,  originally  King's  College,  New  York,  restored  surgery 
to  the  position  of  an  independent  professorship,  which  was  assigned  to  it  in  1767, 
and  Dr.  Valentine  Mott  was  appointed  to  the  chair. 


av%(;|i{N\ 


Fig.  4.— Valentine  Mott  (17S5-1S65). 


Valentine  Mott  (1785-1865)  was  born  at  Glen 
Cove,  Long  Island,  August  20th,  1785.  His  father. 
Dr.  Henry  Mott,  a  native  of  Hempstead,  Long 
Island,  was  the  son  of  Adam  Mott,  an  Englishman 
and  disciple  of  George  Fox,  the  founder  of  the 
sect  of  Friends.  He  was  educated  at  a  private 
school  at  Newton,  where  his  father  practised  his 
profession,  and  at  the  age  of  nineteen  entered  the 
office  of  his  relative.  Dr.  Valentine  Seaman,  a 
prominent  surgeon  of  the  New  York  Hospital. 
Young  Mott  remained  with  Dr.  Seaman  from 
1804  until  1807,  when  he  graduated  from  the 
Medical  Department  of  Columbia  College,  in 
which  Dr.  Wright  Post  was  the  professor  of 
anatomy  and  surgery.  Soon  after  graduation  Dr. 
Mott  visited  London,  and  became  the  pupil  of  Sir 

Astley  Cooper,  then  the  foremost  surgeon  of  that  city.  He  spealcs  of  profiting 
by  the  teachings  of  the  two  Clines,  Abernethy,  the  two  Blizards,  and  Sir  Everard 
Home.  He  remained  in  London  two  years,  diligently  working  in  the  hospitals 
and  assisting  Cooper  in  his  operations.  He  then  visited  the  Edinburgh  school 
and  attended  the  lectures  of  Gregory,  Home,  Duncan,  Hope,  Monroe,  and  John 
Thompson.  On  returning  to  New  York  in  the  following  spring,  1809,  Dr.  Mott 
obtained  the  consent  of  the  trustees  of  Columbia  College  to  deliver  a  course  of 
lectures  and  demonstrations  on  operative  surgery,  1810,  in  the  anatomical  rooms  of 
Columbia  College.  He  had  to  secure  his  own  material  by  stealth,  but  he  was  amply 
repaid  by  the  success  of  his  lectures,  which  he  claimed  were  the  first  "private  lec- 
tures on  any  medical  subject"  in  this  city,  and  he  states  that  he  was  "the  first  to 
demonstrate  to  a  class  the  steps  of  surgical  operations,  as  then  taught  and  practised 
by  the  highest  professional  authorities."  To  these  lectures  he  attributed  his  ap- 
pointment to  the  professorship  of  surgery  in  Columbia  College,  1811,  which  imme- 
diately followed.  This  appointment  was  actually  made  on  the  advice  of  his  pre- 
ceptor, Dr.  Wright  Post,  then  professor  of  anatomy  and  surgery  in  the  College  of 
Physicians  and  Surgeons,  as  well  as  in  Columbia  College.  He  continued  in  this  posi- 
tion until  1826,  when  the  professors  resigned  in  a  body  on  account  of  differences 
with  the  regents.    The  Rutgers  Medical  College  was  then  organized,  and  Dr.  Mott 


14  .1.AIERICAX  PRACTICE  OF  SURGERY. 

entered  the  faculty  as  professor  of  surgery.  Tltis  school  continued  but  five  yeare. 
Dr.  ^lott  was  next  appointed  professor  of  operative  surgery  and  surgical  anatomy  in 
the  College  of  Physicians  and  Stu-geons.  a  position  -n-hich  he  resigned  in  1834,  on  ac- 
count of  faihng  health.  He  now  travelled  extensively  in  Etu-ope,  Asia,  and  Africa. 
On  his  retiu-n  he  tinited  in  the  effort  to  estabhsh  the  Medical  Department  of  the  Uni- 
A'ersity  of  Xew  York,  and  in  1S40  was  appointed  the  professor  of  surgerj-.  Though 
the  school  had  a  verj^  able  faculty,  the  fame  of  Dr.  Mott  was  its  greatest  attraction 
to  students,  and  its  classes  soon  far  exceeded  any  hitherto  gathered  in  this  city.  In 
1850  he  resigned  this  position  and  again  -\isited  Europe.  On  his  return  he  was  ap- 
pointed emeritus  professor  of  operative  surgerj'  and  surgical  anatomy  in  the  College 
of  Physicians  and  Surgeons,  and  commenced  his  cotu-se,  November  7th,  1850,  with 
an  address  on  "Reminiscences  of  !MecUcal  Teaching  and  Teachers  in  New  York," 
an  interesting  re\"iew  of  the  progress  of  surgery  in  this  city  for  half  a  century.  In 
1852  he  accepted  the  position  of  emeritus  professor  of  sm-gery  in  the  ^ledical  De- 
partment of  the  University  of  New  York,  which  he  held  until  his  death,  gi%'ing  an- 
nual coitrses  of  lectures,  cliiefly  chnicaL  He  died  after  a  short  illness  from  embolism 
affecting  the  right  leg,  April  26th,  1865,  his  last  words  being,  "Order,  truth,  punctu- 
aUty.'"' 

Dr.  Gross  says :  "  The  personal  appearance  of  Dr.  Mott  was  eminently  prepos- 
sessing. Tall  and  erect,  with  broad  shoulders  and  a  fine  muscular  development, 
he  had  an  open,  handsome  countenance,  a  frank,  manlj'  exjoression,  and  a  dignified 
yet  cordial  manner.  His  statui'e  was  fully  six  feet,  his  forehead  high  and  promi- 
nent, the  mouth  small,  the  nose  aquUiae,  the  chin  round  and  dimpled,  the  eye 
large,  of  hazel  hue,  and  shaded  by  a  hea^^  brow,  and  the  hau"  in  early  life  nearly 
black,  with  a  slight  iacliQation  to  brownish.  His  features  were  regular,  and  indic- 
ative of  the  benevolence  which  formed  so  remarkable  a  trait  in  his  character. " 

The  late  Dr.  Joseph  ^I.  Smith,  who  was  present  as  a  medical  student  when  Dr. 
Mott  made  his  first  appearance  in  the  lectm'e-room,  says:  "When  Dr.  Mott 
appeared  iu  the  lecture-room  of  the  College  of  Physicians  and  Surgeons,  soon  after 
his  return  from  Europe,  in  company  with  the  professor,  his  appearance  made  a 
marked  and  most  favorable  impression  upon  the  class.  His  dress  was  scrupu- 
lously neat,  his  hah"  powdered,  and  his  bearing  com'tly  and  dignified.  All  of  us 
regarded  liim  with  a  feeling  of  deference  amoimting  to  awe. '" 

The  cjualifications  of  Dr.  }.Iott  as  an  educator  were  of  the  highest  order.  He 
was  a  careful  and  accurate  student  of  the  medical  and  collateral  sciences,  and 
based  his  practice  of  surgery  upon  the  principles  which  the}*  inculcated.  He  had 
been  trained  at  home  in  the  school  of  Hunter  bj'  his  preceptor,  Dr.  Wright  Post, 
and  abroad  by  Home,  Abemethy,  and  Cooper.  He  was  the  legitimate  successor 
of  Dr.  John  Jones  and  Dr.  Wright  Post  in  la}Tng  broad  and  deep  the  foundations 
of  sui'gical  education,  not  only  in  the  schools  of  Xew  York,  but  in  the  colleges  of 
the  coimtry  organized  by  graduates  of  these  metropolitan  schools. 

The  successor  of  Mott  in  the  College  of  Physicians  and  Surgeons,  X'ew  York, 
was  Dr.  Alexander  H.  Stevens,  a  gi-aduate  of  the  University  of  Pennsylvania  in 
ISll.    Stevens  was  trained  in  the  school  of  Phvsick,  and  learned  the  science  of 


INTRODUCTION. 


15 


surgery  as  taught  by  Hunter.  His  graduating  thesis  was  "On  the  Proximate 
Cause  of  Inflammation,"  which  involved  a  discussion  of  first  principles;  but  so 
well  did  he  accomplish  his  task  that  his  essay  received  complimentary  notices 
from  Dr.  Rush  and  others.  His  teaching  was  characterized  by  a  thorough  ex- 
position of  each  subject  in  simple  but  terse  language,  with  quaint  and  striking 
illustrations. 

Alexander  Hodgden  Stevens  (17S9-1S69)  was  a  native  of  New  York  City.  He 
was  a  graduate  of  Yale  College  in  1807,  and  of  the  Medical  Department  of  the  Uni- 
versity of  Pennsylvania  in  1811.  In  1814  he  was  appointed  professor  of  surgery  in 
the  New  York  Medical  Institute,  and  in  1818  he  became  one  of  the  visiting  surgeons 
to  the  New  York  Hospital.  In  1826  he  was  appointed  professor  of  surgery  in  the 
College  of  Physicians  and  Surgeons,  as  the  successor  of  Mott.  He  retired  in  1838 
on  account  of  failing  health,  and  was  made  emeritus  by  the  board  of  regents.  He 
died  in  1869. 


,;  ^^    S^^  -^ 


The  true  successor  of  Stevens  was  Dr.  Willard  Parker,  though  the  chair  of 
surgery  was  occupied  for  two  sessions  by  Dr.  Alban  G.  Smith,  of  Kentucky. 
Parker  became  the  professor  of  surgery  in  1840,  having  been  called  from  the 
Cincinnati  College,  Ohio.  He  was  a  graduate  of  the  Harvard  Medical  College 
and  a  private  pupil  of  Dr.  Jolin  C.  Warren.  Thus  it  happened  that  the  chair  of 
surgery,  once  occupied  by  Jones  and  Post,  then  made  illustrious  by  Mott,  one 
of  its  own  pupils,  next  filled  by  a  representative  of  Physick,  was  now  to  be  given 
to  a  student  of  Warren. 

Parker  had  many  of  the  cjualifications  of  the 
best  class  of  teachers.     His  very  presence  and  M 

personality  commanded  the  confidence,  respect,  ^ 

and  even  admiration  of  students.  His  mental 
attributes  and  his  temperament  rendered  his 
teaching  practical  rather  than  theoretical  and 
speculative.  He  readily  grasped  the  essential 
facts  of  any  subject  matter,  and  at  once  en- 
deavored to  estimate  their  practical  value.  This 
peculiarity  of  his  teaching  was  attractive  to 
students  and  practitioners,  and  always  gave 
him  large  and  attentive  audiences.  His  special 
characteristics  as  a  teacher  of  surgery  were  seen 
to  the  best  advantage  in  the  clinics  which  he 
organized  in  the  lecture-room  of  the  college, 

the  first  of  the  kind  in  this  coimtry.  Here,  in  a  familiar  manner,  he  illustrated 
the  diagnosis  and  treatment  of  surgical  diseases  and  applied  the  principles 
which  he  taught  to  practice.  The  influence  of  such  instruction,  continued  for  a 
generation,  upon  the  practice  of  surgery  in  this  country  cannot  be  estimated. 


Fig.  5. — Willard    Parker 
(1800-1SS4). 


16  MIERICAN  PRACTICE  OF  SURGERY. 

It  is  certain  that  scores  of  graduates  from  the  school  ckiring  that  period  became 
reputable  practitioners,  and  many  attained  to  distinction  as  teachers. 

Draper,  his  student  and  biographer,  states  that  it  was  "  in  his  character  as 
a  public  teacher  that  Parker  impressed  himself  most  powerfully  upon  all  who 
came  within  the  sphere  of  his  attractions.  He  loved  to  teach ;  he  was  inspiring 
and  suggestive ;  there  was  something  about  his  enthusiasm  that  was  contagious ; 
he  never  failed  to  be  interesting  and  to  inspire  others  with  something  of  the  en- 
ergy that  swa3'ed  his  own  soul;  he  was  alwaj's  aspiring  to  the  highest  and  .best 
in  professional  knowledge,  and  was  constantly  helping  to  lift  others,  ambitious 
to  attain  it,  to  a  higher  plane." 

Willard  Parker  (1800-18S4)  was  born  September  2d,  ISOO,  in  Hillsboro,  N.  H. 
He  graduated  from  Harvard  College  in  1826,  and  in  1827  was  appointed  house  phy- 
sician to  the  Marine  Hospital  at  Chelsea,  where  he  spent  two  years.  He  was  a  pupil 
of  Dr.  John  C.  Warren,  and  served  one  year  as  house  sm-geon  in  the  Massachusetts 
General  Hospital.  He  graduated  in  medicine  from  the  Harvard  School  in  1830,  and 
soon  after  accepted  the  professorship  of  anatomy  in  the  Berksliire  ^ledical  CoUege 
at  Pittsfield,  Mass.  In  1832  he  delivered  a  course  of  lectures  on  surgery  in  the 
same  institution.  In  1836  he  was  appointed  professor  of  sm-gery  in  the  Cincinnati 
Medical  CoUege,  and  in  1839  accepted  the  professorship  of  smgery  in  the  College  of 
Phj^sicians  and  Smgeons  of  New  York,  a  position  he  held  thirty'  years.  On  retiring 
he  was  appointed  emeritus  professor,  and  continued  in  that  relation  to  the  college 
until  his  death  in  1884. 

In  the  year  1805  the  teaching  of  surgerj'  was  divorced  from  anatomy  and  ob- 
stetrics, and  erected  into  an  independent  professorship,  by  the  governing  body 
of  the  ]\Iedical  Department  of  the  University  of 
Pennsylvania,  originally  the  Medical  Department 
of  the  College  of  Philadelphia,  and  Dr.  Philip 
Syng  Physick  was  appointed  to  the  new  position. 
He  was  admnably  adapted  b}^  ultimate  association 
with  Hunter,  in  his  experimental  work,  to  inau- 
gurate in  that  pioneer  school  the  doctrines  taught 
by  his  master.  It  was  the  concm"rent  testimony  of 
contemporary  wTiters  that  Dr.  Physick's  teaching 
of  surgery  placed  it  on  a  rational  and  enduring 


1.     \ 


\ 


basis  as  a  science  and  an  art. 


Fia.  6.  —  Philip  S\-ng  Phvsick  -r,,  ...       r^  ,-„       .   ,      ,^_„„    ,  „„„ 

(176S-1S37)       "  Thihp   Syng  Physick   (1768-1837)    was  born   m 

Philadelplna  on  the  7th  day  of  July,  1768.  He  was 
of  English  descent  and  received  his  coUegiate  education  at  the  University  of  Penn- 
sylvania, from  which  he  graduated  at  the  age  of  seventeen.  He  studied  medicine  in 
the  office  of  a  phj-sician  for  three  years,  and  in  1789,  at  the  age  of  twenty-one, 
went  to  London  and  became  the  private  pupil  of  John  Hunter  and  a  member  of  his 
family.  He  was  appointed  a  member  of  the  house  staff  of  St.  George's  Hospital 
through  the  influence  of  his  master,  with  whom  he  seems  to  have  been  a  favorite, 


INTRODUCTION.  17 

for  at  the  close  of  his  residence  Hunter  requested  him  to  become  his  partner.  He 
visited  Edinburgh  and  remained  a  year  attending  a  course  of  instruction,  receiving 
his  medical  degree  in  1792,  at  the  age  of  twenty-four. 

Dr.  Physiclc  returned  to  Philadelpliia  and  began  practice  under  the  most  favor- 
able conditions.  In  1794  he  was  elected  a  surgeon  of  the  Pennsylvania  Hospital, 
and  in  ISOO  he  was  in^dted  to  lecture  on  surgery  to  the  students  in  the  university 
school.  In  1805  the  professorship  of  surgery  was  created  in  the  university,  and  Dr. 
Physick  was  appointed  to  the  chair.  He  held  the  position  thirteen  j-ears,  when  he 
rehnquished  it  and  accepted  the  chair  of  anatomy,  which  he  retained  until  1830  in 
co-operation  with  a  colleague.    He  died  in  1837. 

Dr.  Physick  is  described  as  a  man  of  mediujn  height,  ■with  pale,  regular,  classic 
features;  in  manners  reserved  to  the  degree  of  shyness;  as  to  health,  the  victim 
of  indigestion  and  catarrh;  and  in  temperament  pessimistic,  forbidding,  and 
devoid  of  a  sense  of  hmnor.  In  the  daily  routine  of  practice  he  was  prompt  and 
precise,  requiring  his  patients  only  to  answer  questions,  and  never  allowing  them 
to  indulge  in  explanations.  The  same  precision  marked  his  operations,  and, 
having  a  small,  delicate,  and  facile  hand,  every  step  in  the  procedure  was  taken 
with  an  accuracy  that  impressed  on  the  student  a  most  useful  lesson. 

Dr.  John  Bell  remarks:  "  Dr.  Physick  was  from  this  time  in  possession  of  the 
widest  field  for  the  exercise  of  his  talents."  He  was  "listened  to  by  the  large 
class  in  the  university,  through  the  members  of  which  he  could  disseminate  the 
principles  of  surgery  imbibed  from  his  celebrated  preceptor,  John  Hunter^ 
strengthened  and  enforced  by  his  o'mi  meditation  and  personal  experience  ob- 
tained m  hospital  and  private  practice." 

Dr.  Joseph  Carson,  the  historian  of  the  Medical  Department  of  the  Univer- 
sity of  Pennsylvania,  thus  speaks  of  Dr.  Physick's  method  of  instruction :  "  The 
lectm-es  were  carefully  wi'itten  out  and  delivered  with  the  manuscript  before 
him  or  in  hand;  for  it  was  an  axiom  with  him  that,  on  so  miportant  an  occasion 
as  the  instruction  of  youth  in  an  art  so  necessary  to  the  well-being  and  happi- 
ness of  mankind,  every  care  should  be  taken  to  render  the  inculcation  of  prin- 
ciples and  practice  clear  to  the  comprehension  of  students.  .  .  .  His  dignified 
bearing  and  imposing  presence,  his  emphatic  manner,  and  painstaking  execution 
of  his  duties  deeply  impressed  his  pupils  and  commanded  the  profoundest  def- 
erence." 

Intimately  associated  with  Dr.  Physick  in  the  duties  of  his  professorship, 
from  the  year  1807  to  1818,  was  his  nephew.  Dr.  John  Syng  Dorsey. 

John  Syng  Dorsey  (1783-1818)  was  born  in  Philadelphia,  December  23d,  1783. 
His  mother  was  a  sister  of  Dr.  Philip  Syng  Physick.  He  was  educated  at  the  Friends' 
School,  Philadelphia.  At  the  age  of  fifteen  he  entered  the  office  of  liis  uncle,  as  a 
student  of  medicine,  and  in  1802,  at  the  age  of  nineteen,  he  graduated  from  the 
Medical  Department  of  the  University  of  Pennsylvania.  In  the  foUomng  year,  1803, 
he  visited  London  for  the  purpose  of  continuing  his  studies,  vdih  letters  of  introduc- 
tion from  his  uncle  to  Sir  Everard  Home,  the  brother-in-law  of  John  Hunter,  then 


18  AMERICAN  PRACTICE  OF  SURGERY. 

one  of  the  most  eminent  surgeons  of  that  citj^.  He  next  visited  Paris,  where  he  was 
attracted  by  Boyer,  whom  he  most  frequently  mentions  in  his  correspondence.  He 
returned  in  1S04  and  began  practice  in  Philadelphia.  Soon  after,  he  became  the 
prosector  to  his  uncle,  the  professor  of  surgery  in  the  university,  and  in  1807  he  was 
appointed  adjunct  professor  of  surgery.  In  1808  Dr.  Dorsey  was  appointed  one 
of  the  surgeons  of  the  Pennsylvania  Hospital,  and  in  181.3  he  published  a  work  en- 
titled "The  Elements  of  Surgery,"  in  two  volumes.  In  1818  he  was  appointed  pro- 
fessor of  anatomy  on  the  death  of  his  predecessor,  Dr.  Wistar.  Dr.  Dorsey,  how- 
ever, was  not  destined  to  enjoy  the  advantages  and  the  honors  which  this  position 
gave  him.  He  delivered  a  brilliant  introductory  to  the  course  of  lectures  which  he 
had  plaimed,  on  the  second  day  of  November,  1818,  but  was  attacked  with  typhus 
fever  on  the  evening  of  that  day,  and  died  on  the  twenty-third  day  of  the  same 
month,  at  the  age  of  thirty-five. 

The  appointment  of  Dorsey  to  the  position  of  adjunct  professor  was  rendered 
necessary  on  account  of  the  frequent  attacks  of  illness  of  his  uncle,  thereby  ren- 
dering his  attendance  on  lectures  uncertain.  Dorsey  was  an  accomplished  lect- 
urer and  a  practical  surgeon  of  great  skill.  Professor  Chapman,  his  colleague, 
says  that,  with  the  exception  of  Dr.  Physick,  "He  was  indisputably  the  most 
accomplished  surgeon  in  our  country,  and  this  high  praise  is  conceded  to  him 
on  account  of  the  number  and  variety,  the  difficulty  of  his  operations,  and  the 
skill,  dexterity,  and  boldness  with  which  they  were  performed.  Clear  in  his 
views  and  of  sound  judgment,  he  had  great  mechanical  ingenuity,  delicacy  of 
touch,  and  promptness  of  decision;  and  hence  in  conducting  an  operation,  how- 
ever new  or  complicated,  there  was  a  tone  and  firmness  of  manner  which  always 
inspired  confidence  and  success.  As  a  teacher  of  medicine  his  merits  were  great 
and  universally  acknowledged."  He  was  also  an  artist  of  such  skill  as  to  attract 
the  favorable  notice  of  persons  prominent  in  that  profession. 

Dr.  William  Gibson  (1788-1868)  was  the  successor  of  Physick,  and  main- 
tained the  reputation  of  the  University  Medical  College,  Philadelphia,  for  thirty- 
six  years.  He  was  a  graduate  of  Princeton  College,  where  he  took  high  rank  as 
a  classical  scholar.  He  pursued  his  medical  studies  in  Edinburgh,  and  was  a 
pupil  of  John  and  Charles  Bell.  He  graduated  from  the  Edinburgh  school  with 
distinction,  his  thesis  on  "Necrosis,"  written  in  Latin,  attracting  attention  on 
account  of  its  classical  style.  On  his  return  he  was  appointed  professor  of  sur- 
gery in  the  University  of  Maryland,  and  in  1819  he  succeeded  Physick  in  the 
chair  of  surgery  in  the  Medical  Department  of  the  University  of  Pennsylvania, 
a  position  which  he  held  until  1855.    He  died  in  Savannah,  Ga.,  in  1868. 

Gibson  was  a  teacher  of  surgery  who  always  interested  students  by  his  positive 
and  earnest  manner  of  delivery  and  by  his  accuracy  and  clearness  of  statement. 
In  1824  he  published  his  "Institutes  and  Practice  of  Surgery,"  which  passed 
through  several  editions  and  was  for  many  years  the  accepted  text-book  of  sur- 
gery.   Thus  as  a  teacher  of  surgery  in  the  largest  medical  school  in  the  country 


INTRODUCTION.  19 

and  as  author  of  the  text-book  of  its  theory  and  practice  which  was  widely  ac- 
cepted by  the  profession,  Gibson  was  one  of  the  early  promoters  of  a  sound 
surgical  education  for  upward  of  a  generation. 

Dr.  Henry  H.  Smith  (1815-90)  succeeded  Gibson  in  1855.  He  was  a  native 
of  Philadelphia,  and  received  both  his  collegiate  and  medical  education  at  the 
University  of  Pennsylvania,  where  he  graduated  in  medicine  in  1837.  He  was 
the  first  of  its  graduates  to  be  appointed  to  its  chair  of  surgery.  He  is  spoken 
of  as  "  excellent  and  unexceptional  in  his  style  of  speaking — quiet,  self-possessed, 
systematic,  and  thorough."  His  most  important  contribution  to  the  practice  of 
surgery  was  a  work  entitled  "A  System  of  Operative  Surgery."  He  resigned 
the  professorship   of    surgery   in  1871,  and  was  ^ 

appointed  emeritus. 

Dr.  D.  Hayes  Agnew  (1818-92)  succeeded 
Smith  in  1871.  He  was  a  native  of  Lancaster,  Pa., 
and  a  graduate  from  the  University  Medical  Col- 
lege, Philadelphia.  After  a  brief  residence  in  the 
country,  he  located  in  Philadelphia,  and  began 
private  teaching  of  medical  students.  His  success 
as  a  teacher  was  very  great,  and  he  attracted 
large  classes  of  students  from  all  sections  of  the 
country.  In  1854  he  was  appointed  one  of  the  sur- 
geons of  the  Pennsylvania  Hospital,  and  while  in 

...  ,  .1     1       •      1  Fig.  7.  — D.  Hayes  Agnew  (ISIS- 

that  position  he  created  a  pathological  museum.  jggo^ 

In  1863  he  accepted  the  position  of  demonstrator 

of  anatomy  and  lecturer  on  clinical  surgery  in  the  Medical  Department  of  the 

university.    In  1870  he  was  selected  as  professor  of  operative  surgery;  in  1871 

he  became   professor  of  the  principles  and  practice  of  surgery  in  the  same 

institution. 

Agnew  fittingly  closes  the  history  of  surgical  teaching  in  the  Medical  Depart- 
ment of  the  University  of  Pennsylvania  during  the  period  mider  review.  In- 
structed in  the  policies  of  this  school,  and  already  distinguished  as  a  surgeon  and 
skilled  as  a  teacher  by  a  large  experience  as  an  instructor  in  anatomy,  pathology, 
operative  and  clinical  surgery,  he  entered  upon  his  duties  not  only  qualified  to 
maintain  but  to  advance  its  reputation  as  the  true  exponent  of  the  science  and 
art  of  surgery  as  formulated  by  Physick. 

In  1806  Dr.  John  C.  Warren  became  associated  with  his  father.  Dr.  John 
Warren,  in  teaching  anatomy  and  surgery,  and  succeeded  to  the  full  professor- 
ship on  the  death  of  the  elder  Warren  in  1815. 

John  Collins  Warren  (1778-1856)  was  born  in  Boston,  August  1st,  1778.  He  was 
the  eldest  son  of  Dr.  John  Warren,  the  founder  of  the  Harvard  Medical  College.  He 
graduated  from  Harvard  College  in  1797,  and  after  a  year's  delay  began  the  study 
of  medicine.    In  1799  he  went  to  London  and  entered  Guy's  Hospital  as  a  dresser 


20 


AMERICAN  PRACTICE  OF  SURGERY. 


Fig.  S.  — John  C.  Warren  (177S-1S56). 


to  Mr.  William  Cooper,  senior  surgeon  to  that  hospital,  who  was  soon  after  suc- 
ceeded by  JMr.  Astle}'  Cooper,  his  nephew.  After  a  year's  service  he  left  London  for 
Edinburgh,  where  he  attended  the  lectm-es  of  Monroe  and  Jolm  and  Charles  Bell, 
and  received  his  medical  degree.  He  visited  Paris,  where  he  remained  one  year 
attending  lectures,  and  then  returned  home  in  1802.  He  was  the  founder  of  the 
Massachusetts  General  Ho.spital  and  one  of  its  surgeons  until  his  death.  In  1806  he 
was  associated  with  his  father  in  the  chair  of  anatomy  and  surgerv,  and  on  the  death 

of  the  latter  in  1815  he  became  full  professor, 

..^^^^^s  and  continued  in  that  pbsition  until  1847,  when 

^^  a  professorship  of  siu-gery  was  created,  and  he 

t  became  the  emeritus    professor.    He  died  May 

/'  4th,  1856. 

He  was  educated  in  the  traditions  of  the 
Edinburgh  school  and  was  influenced  in  his 
teaching  and  practice  by  the  precedents  of 
British  surgery. 

The  successor  of  ^^"arren  in  the  Harvard 
school,  in  1847,  was  Dr.  George  Ha3T\'ard 
(1791-1863).  He  was  a  natiA^e  of  Boston,  a 
graduate  of  Harvard  College  in  1809,  but  he 
graduated  in  medicine  from  the  University  of 
Pennsylvania  in  1812.  As  a  teacher,  it  is  stated,  "  thoroughly  versed  in  the 
principles  and  theorj'  of  surgery,  he  was  a  remarkably  practical  and  popular 
teacher  in  the  professor's  chair  and  at  hospital  clinics."    He  died  in  1S63. 

In  1849  Dr.  Henrj-  J.  Bigelow  succeeded  HajTvard  as  professor  of  surgery  in 
the  Harvard  school,  and  continued  in  that  position  until  1882,  a  period  of  thirty- 
three  jTars.     Bigelow  was  qualified  by  birth,  ^..^—^ 
mental  endowments,  and  preparatory  training, 
not  only  to  maintain  the  high  standard  of  edu- 
cational   qualifications    which    the    Han-ard 
school  required  of  its  graduates,  but  to  advance 
that  standard  so  that  it  kept  pace  with  the 
rapid  development  of  the  medical  sciences  dur- 
ing the  period  of  his  service.    It  is  well  stated 
of  him  that  as  "inventor  and  discoverer  by 
nattu-e,  his   constant  aim  was  to  enlarge  the 
boundaries  of  his  profession,  and  to  this  end  his 
fertility  in  ideas  and  remarkable  mechanical 
ingenuity  came  to  his  aid."    He  was  pre-emi- 
nently a  master  of  both  the  science  and  the  art 
of  surgery,  and  in  his  teachmg  he  was  able  so  to  combine  principles  and  prac- 
tice that  the  student  became  proficient  m  both  branches  of  the  subject. 

Henry  Jacob  Bigelow  (1818-1890)  was  a  native  of  Boston,  and  son  of  Dr.  Jacob 


\ 


Fig.  9.  —  Henry  Jacob  Bigelow  (ISIS- 
1S90). 


INTRODUCTION.  21 

Bigelow.  He  graduated  at  Harvard  College  in  1837,  and  received  his  medical  degree 
from  the  same  institution  in  1841.  In  1845  he  began  teaching  surgery  in  the  Tre- 
mont  Street  iledical  School,  and  in  1849  he  was  appointed  professor  of  surgery 
in  the  Harvard  Medical  College,  a  position  which  he  held  until  1886,  a  period  of  thirty- 
seven  years.  He  was  elected  a  member  of  the  surgical  staff  of  the  JIassachusetts 
General  Hospital  in  1S46.    He  died  in  1890. 

This  brings  our  narrative  of  the  pioneer  medical  schools  to  the  close  of  the 
Normative  period  in  the  eA^olution  of  American  surgery.  They  had  laid  broad  and 
deep  the  foimdations  on  which  the  character  of  its  future  practice  was  to  be  con- 
stmcted.  During  the  quarter  of  a  century  which  has  since  elapsed  these  schools 
have  been  the  master  builders  on  those  fomidations,  and  to-day  they  are  miiver- 
sally  recognized  as  occupying  a  foremost  position  among  the  world's  best  insti- 
tutions for  medical  instruction.  Along  the  line  of  succession  to  the  fotmders  of 
surgical  education  in  these  fii'st  schools,  we  recognize  the  names  of  surgeons 
whose  achievements  in  practice  are  the  crowning  glory  of  American  surgery. 

Not  less  illustrious  in  the  annals  of  surgery  are  the  names  of  many  of  the 
graduates  who  went  forth  from  these  schools,  imbued  with  the  highest  ideals  of 
professional  character  and  animated  by  the  adventurous  spirit  which  pervaded 
all  ranks  of  our  yoimg  communities,  to  establish  other  schools  at  the  centres  of 
population.  The  promoters  of  the  new  colleges  were  more  frequently  enthusi- 
astic young  surgeons,  whose  ambition  found  its  most  natural  expression  in  teaching 
others  the  science  and  art  of  their  profession.  We  have  not  space  to  follow  the 
development  of  these  schools,  nor  would  it  be  instructiA^e  to  dwell  upon  their  indi- 
vidual peculiarities  further  than  is  necessary  to  illustrate  the  American  independ- 
ence of  precedents  and  the  resourcefulness  of  their  promoters,  as  seen  in  the 
organization  of  several  of  the  earlier  schools  by  graduates  of  the  pioneer  colleges. 

In  the  year  1798  the  Medical  Department  of  Dartmouth  College,  at  Hanover, 
N.  H.,  was  established,  at  the  suggestion  of  Dr.  Nathan  Smith,  a  graduate  of 
Harvard  Medical  College.  The  most  interestuig  feature  in  the  organization 
of  this  school  was  the  composition  of  the  faculty,  which  consisted  of  a  single 
person,  viz.,  its  promoter,  Dr.  Nathan  Smith.  For  twelve  years  he  gave  courses 
of  lectiues  on  all  of  the  different  branches  of  medicine  then  taught,  except  two 
coiuses  in  the  department  of  chemistry. 

Nathan  Smith  (1762-1829)  was  born  at  Rehoboth,  Mass.,  September  30th,  1762. 
His  education  was  obtained  at  the  pubhc  school.  At  the  age  of  twenty-four  he  wit^ 
nessed  a  surgical  operation,  which  so  impressed  Mm  that  he  determined  to  study 
medicine,  and  accordingly  apphed  to  the  surgeon  to  be  admitted  to  his  office  as  a 
student.  He  was  directed  to  prepare  himself  for  admission  to  Harvard  College  be- 
fore commencing  the  study  of  medicine,  which  he  promptly  did,  and  was  then  al- 
lowed to  enter  and  register  as  a  student.  After  three  years  of  study  he  located 
in  practice  at  Cornish,  Vt.  Soon  after,  he  attended  the  lectures  on  medicine  and 
collateral  sciences  at  Harvard  College,  from  which  he  received  the  degree  of  Bachelor 
of  Medicine  in  1790.    He  returned  to  his  practice,  wMch  he  pursued  with  marked 


22 


AMERICAN  PRACTICE  OF  SURGERY. 


success  for  five  or  six  j^ears.  During  this  time  lae  became  mucli  impressed  witli  tlie 
low  grade  of  educational  qualifications  of  the  practitioners  with  whom  he  was  iDrought 
in  contact.  On  this  account  his  biographer  states  that  "  he  was  led  to  project  a  med- 
ical institution  in  connection  with  Dartmouth  Col- 
lege, in  order  to  rear  up  for  the  widespread  regions 
of  the  interior  of  New  England  a  race  of  better 
educated,  more  enlightened,  and  more  skilfi.il  phy- 
sicians and  surgeons."  His  plans  being  approved 
by  the  president  of  the  college.  Dr.  Smith  s.ought 
to  better  qualify  himself  for  the  new  duties  by 
attending  the  schools  of  London  and  Edinburgh. 
He  returned  in  September,  1797,  and  early  in  the 
year  1798  began  a  course  of  lectures  which  em- 
braced the  entire  circle  of  the  medical  sciences,  as 
then  imderstood,  and  which  he  repeated  for  twelve 
successive  years. 

In  1813  he  was  invited  to  the  chair  of  "physic 

and  surgery"  in  the  recently  established  Medical 

Department  of  Yale  College,  which  he  accepted. 

He  subsequently  gave  one  course  in  Dartmouth 

"College,  one  in  "\"ermont  University,  and  five  in  the  Medical  Institution  of  Bowdoin 

■College  at  Brunswick,  Maine.     He  died  January  26th,  1829,  in  the  sixty-seventh 

year  of  his  age. 


'Fjq.  10.— Nathan  Smith  (1762- 
1S29). 


In  estimating  the  character  of  Dr.  Nathan  Smith  as  a  surgeon  and  teacher 
of  surgery,  we  have  the  judgment  of  his  colleague  in  the  Yale  Medical  College, 
Prof.  Jonathan  Knight.  He  sa3's:  "For  the  duties  of  a  practical  surgeon,  Dr. 
Smith  was  eminently  qualified.  ...  To  these  he  brought  a  mind  enterprising, 
but  not  rash;  anxious,  yet  calm,  in  deliberation;  bold,  yet  cautious  in  opera- 
tion. .  .  .  There  was  no  formidable  array  of  instruments,  no  ostentatious  prep- 
aration; ...  all  useless  parade  was  avoided.  .  .  .  His  whole  mind  was  bent 
upon  its  performance." 

"As  an  instructor,"  says  Professor  Knight,  "the  reputation  of  Dr.  Smith 
was  high,  from  the  time  he  began  the  business  of  instruction.  .  .  .  That  for 
many  years  he  gave  instruction  upon  all  the  branches  of  medical  and  surgical 
science,  that  this  instruction  was  to  classes  of  intelligent  young  men,  and  that 
many  who  were  thus  instructed  have  become  eminent  in  their  profession,  prove 
not  only  versatility  of  talent,  but  variety  and  extent  of  information,  with  a 
happy  method  of  commimicatuig  it.  .  .  .  He  sought  no  aid  from  an  artificial 
style,  but  merely  poured  forth,  in  the  plain  language  of  conversation,  the  treas- 
ures of  his  wisdom  and  experience.  .  .  .  His  object  was  to  instill  into  the  minds 
of  his  pupils  the  leading  principles  of  their  profession,  not  entering  fully  into  the 
details  of  the  practice,  but  leaving  it  for  them  to  apply  these  principles  to  in- 
dividual cases  as  they  should  present  themselves.  These  principles  he  would 
illustrate  by  appropriate  cases  furnished  by  a  long  course  of  practice,  related 


INTRODUCTION.  23 

always  in  an  impressive,  and  often  in  a  playful  manner,  so  as  at  once  to  gain  the 
attention  and  impress  the  truth  illustrated  upon  the  mind.  ...  He  endeavored 
to  inspire  them,  both  by  precept  and  example,  with  a  love  of  their  profession, 
with  activity  in  the  practice  of  it,  and  a  zeal  for  its  best  interests." 

Of  the  influence  of  Dr.  Smith  upon  the  profession  of  New  England,  Professor 
Knight  remarks:  "His  influence  over  medical  literature  was  equally  extensive. 
This  influence  was  exerted,  through  his  large  acquamtance  among  medical  men, 
by  his  advice  and  example,  as  well  as  more  directly  through  the  medium  of  the 
various  medical  schools  which  were  favored  with  his  instructions.  By  means 
of  his  influence  thus  exerted,  he  effected,  over  a  large  extent  of  country,  a  great 
and  salutary  change  in  the  medical  profession.  The  assertion  that  he  has  done 
more  for  the  improvement  of  physic  and  surgery  in  New  England  than  any  other 
man  will  by  no  one  be  deemed  invidious." 

From  Dr.  Nathan  Smith's  school  at  Dartmouth  many  students  graduated  who 
became  reputable  surgeons,  and  one,  Dr.  Reuben  D.  Mussey,  achieved  a  national 
reputation,  both  as  a  surgeon  and  as  an  educator.  Like  that  of  his  master,  Mus- 
sey's  early  life  was  a  continuous  struggle  to  obtain  an  education  and  prepare  for 
his  future  work.  He  was  evidently  adapted  for  pioneer  duties,  as  he  early  under- 
took experimental  research.  While  a  student,  he  controverted  Dr.  Rush's  the- 
ory of  the  non-absorbent  power  of  the  skin  by  a  series  of  carefully  conducted 
experiments.  His  thesis  on  this  subject  attracted  much  attention.  His  contro- 
versy with  Sir  Astley  Cooper,  in  which  he  maintained  that  a  fracture  of  the 
neck  of  the  thigh  bone  within  the  capsule  could 
unite  by  bone,  illustrated  Mussey's  careful 
study  and  observation,  and  the  tenacity  with 
which  he  held  his  opinions.  As  a  teacher  his 
work  was  in  the  West,  and  chiefly  in  Cincin- 
nati. He  was  the  founder  of  the  Miami  Medi- 
cal College. 

Reuben  Dimond  Mussey  (1780-1866)  was  a 
native  of  Pelham,  N.  H.  His  father  was  a  physi- 
cian, but  the  son  had  to  earn  the  means  to  enable 
him  to  obtain  an  education.  He  graduated  from 
Dartmouth  College,  in  1803,  and  became  a  pupil 
of  Dr.  Nathan  Smith,  and  graduated  in  1806.  ''"'■  ''■''"'''''Zf;  Mussey  (17S0- 
After  three  years  of'  practice  he  attended  the  lect- 
ures in  the  University  of  Pennsylvania,  from  which  he  graduated  in  1809.  He 
located  in  Salem,  Mass.,  and  soon  became  prominent  as  a  successful  surgeon.  He 
began  to  give  lectures  on  different  medical  subjects,  and  in  1822  he  was  appointed 
professor  of  anatomy  and  surgery  in  the  Dartmouth  Medical  School.  In  1833-35  he 
lectured  on  anatomy  and  surgery  in  the  Bowdoin  Medical  College  and  in  1836-37  he 
gave  the  course  on  surgery  in  the  medical  college  at  Fairfield,  N.  Y.  In  1837  he  was 
invited  to  professorships  in  New  York  City,  Nashville,  Tenn.,  and  Cincinnati,  Ohio. 


24  AMERiaO  PRACTICE  OF  SURGERY. 

He  accepted  the  latter  and  became  the  professor  of  surger}-  in  the  Ohio  Medical  Col- 
lege, a  position  which  he  held  fourteen  years.  He  then  organized  the  Miami  Medical 
College,  and  remained  connected  vnth  it  until  he  retired  from  active  duties,  in  1858, 
and  located  in  Boston.    He  died  in  1866. 

Gross  speaks  verj'  disparagingly  and  even  contemptuously  of  Mussey's  per- 
sonality and  his  power  as  a  teacher.  He  says  :  "  Mussey  was  of  low  stature,  of 
an  attenuated  form,  with  high  cheek  bones,  a  prominent  chin,  a  small  gray  eye, 
and  ungraceful  gait."  As  a  lecturer  he  "was  dull  in  the  extreme.  He  was- not 
only  slow  in  his  delivery,  but  deficient  in  his  animation  and  in  grace  of  manner. 
His  words  came  forth  tardily,  as  if  he  were  in  doubt  as  to  their  precise  import  or 
as  to  the  construction  that  might  be  put  upon  them  by  his  hearers."  His  lect- 
ures were  not  "  learned,  profound,  or  discursive,  ...  for  Mussey  was  not  a  man 
of  reading."  He  adds:  "If  w-e  may  be  able  to  credit  those  who  professed  to  be 
able  to  judge  of  them  and  who  had  listened  to  other  teachers  on  similar  topics, 
his  lectures  must  have  been  instructive."  Probably  Gross  places  the  true  esti- 
mate on  Mussey's  teachmg  in  his  conclusion:  "His  lectures  owed  their  chief 
value  to  their  practical  adaptation  to  the  daily  and  hourly  wants  of  the  practi- 
tioner." 

The  abilities  of  Dr.  Nathan  Smith  as  an  educator  and  his  activity  in  estab- 
lishing new  medical  schools  Avere  transmitted  to  his  son,  Dr.  Nathan  R.  Smith. 
For  more  than  half  a  century  as  a  teacher  in  many  medical  schools,  and  as  an 
author  and  inventor,  the  latter  exerted  a  marked  mfluence  upon  the  progress 
of  scientific  surgery.  He  was  an  attractive  lecturer,  a  skilful  operator,  and  an 
mgenious  uiventor.  One  of  his  most  useful  publica- 
tions is  his  "Memoirs,"  m  which  he  reproduced  the 
substance  of  his  father's  teaching.  His  most  hnpor- 
tant  invention  was  an  anterior  splint  for  fractm'es  of 
the  thigh. 

Nathan  Ryno  Smith  (1797-1877)  was  a  native  of 
New  Hampshire.  He  graduated  from  Yale  College  in 
1  SI  7,  studied  medicine  under  his  father's  direction,  and 
received  his  degree  from  the  Jefferson  Medical  College, 
Philadelphia,  in  1820.  He  located  in  Burlington,  Vt., 
^  ,  and  in  1825  founded  the  Medical  Department  of  the  Uni- 

^^  J^''  \  1'^, '      versity  of  Vermont,  and  was  appointed  its  first  professor 
of  anatomy  and  surgery.     In  1826  he  was  called  to  the 
""",^^^5^" —■'!"°  ^"^  ^     chair  of  anatomy  in  the  Jefferson  Medical  College,  Phila- 
delphia.     In  1827  he  became  professor  of  surgery  in 
the  University  of  Maryland,   Baltimore,   and  in  1828  accepted  the  chair  of  medi- 
cine in  the  Transylvania  University,  Lexington,   Ky.      After  twelve  years'  service 
he  returned  to  Baltimore  as  professor  of  surgery  in  the  University  of  Maryland.    He 
retained  this  position  until  1870,  when  he  resigned  and  became  professor  of  chnical 
surgerv-    He  died  in  1877. 


INTRODUCTION. 


25 


In  1817  the  Medical  Department  of  Transylvania  University  was  established 
at  Lexington,  Ky.,  and  the  first  opportunities  were  offered  to  obtain  a  medical 
education  in  the  Southwest.  The  founder  of  this  school  was  Dr.  Benjamin  W. 
Dudley,  one  of  the  most  eminent  surgeons  of  that  period.  There  was  no  medical 
college  west  of  the  Alleghanies,  and  the  need  of  facilities  for  medical  instruction 
of  a  rapidly  increasing  profession  in  the  great  Southwest  was  very  pronounced. 
Dr.  Yandell,  the  historian  of  "Pioneer  Surgery  in  Kentucky,"  remarks  as  fol- 
lows :  "  The  history  of  the  Medical  Department  of  Transylvania  University  .  .  . 
would  practically  cover- Dr.  Dudley's  career,  and  would  form  a  most  interesting 
chapter  on  the  development  of  medical  teaching  in  the  Southwest.  .  .  .  Dr. 
Dudley  created  the  medical  department  of  the  institution  and  directed  its 
policy." 

The  testimonies  in  favor  of  Dudley's  qualifications  as  a  teacher  of  surgery 
are  numerous.  One  of  his  colleagues  thus  speaks  of  him  as  a  professor:  "He 
was  magisterial,  oracular,  conveying  the  idea  always  that  the  mind  of  the  speaker 
was  troubled  with  no  doubt.  He  was  always,  in  the  presence  of  his  students, 
not  the  model  teacher  only,  but  the  dignified,  ui'bane  gentleman;  conciliating 
regard  by  his  gentleness,  but  repelling  any  approach  to  familiarity,  and  never, 
for  the  sake  of  raising  a  laugh  or  eliciting  a  little  momentary  applause,  descend- 
ing to  coarseness  of  expression  or  thought.  So  that  to  his  pupils  he  was  always 
and  everywhere  great.  As  an  operator  they  thought  he  had  distanced  competi- 
tion. As  a  teacher  they  thought  he  gave  them  not  what  was  in  the  books,  but 
what  the  writers  of  the  books  had  never  understood.  They  were  persuaded  that 
there  was  much  they  must  learn  from  his  lips  or  learn  not  at  all." 

Benjamin  Winslow  Dudley  (17S5-1S70)  was  born  in  Virginia,  April  25th,  1785. 
When  one  year  of  age  his  father  removed  to  Lexington,  Ky.,  where  he  was  reared, 
His  opportunities  for  obtaining  an  education  were  very 
meagre.  He  studied  medicine  in  the  office  of  a  physi- 
cian and  received  his  degree  from  the  University  of 
Pennsylvania  two  weeks  before  he  was  twenty-one,  in 
1806.  Ambitious  of  success  as  a  surgeon,  he  deter- 
mined, after  two  or  three  years  of  practice,  to  visit 
the  hospitals  abroad.  Not  having  sufficient  means  at 
his  command,  he  purchased  a  flat-boat,  loaded  it  with 
produce,  and  took  it  to  New  Orleans,  where  he  exchanged 
it  for  flour.  This  cargo  he  took  to  Europe  and  sold 
at  a  considerable  advance,  and  with  the  proceeds  pros- 
ecuted his  surgical  studies  for  a  period  of  four  years 
in  the  hospitals  of  Paris  and  London.  He  returned  to 
Lexington  in  1814,  and  rapidly  acquired  reputation  as 
a  surgeon.  In  1817,  largely  through  his  influence,  the 
Medical  Department  of  Transylvania  University  was 
established,  and  Dr.  Dudley  was  appointed  the  professor  of  anatomy  and  surgery. 
He  died  in  1870. 


Fig.  13. — Benjamin  Winslow 
Dudley  (17S5-1S70). 


26 


AMERICAN  PRACTICE  OF  SURGERY, 


In  1826,  Jefferson  Medical  College,  of  Philadelphia,  was  founded  by  Dr. 
George  McClellan,  a  graduate  of  the  Medical  Department  of  the  University  of 
Pennsylvania.  McClellan  was  a  type  of  the  aspiring  and  aggressive  young  sur- 
geons of  that  early  period.  He  had  been  a  pupil  of  Dorsey,  the  assistant  of 
Physick,  a  brilliant  lecturer  and  accredited  author.  Soon  after  his  graduation 
McClellan  began  teaching  anatomy  and  surgery,  and  his  vivacity  of  manner 
and  fluency  of  speech  attracted  large  classes.  It  is  stated  that  as  a  public  teacher 
his  style  was  purely  extemporaneous;  he  became  so  absorbed  with  his  subject 
as  to  be  vmconscious  of  those  around  him.  His  lectures  achieved  a  popularity 
and  produced  an  effect  seldom  equalled.  As  a  practical  surgeon  he  took  rank 
with  the  most  successful  practitioners  of  that  day.  The  school  which  he  foimded 
has  been  one  of  the  largest  contributors,  in  its  graduates,  to  the  ranks  of  eminent 
practical  surgeons  and  teachers. 


George  McClellan  (1796-1847)  was  born  at  Woodstock,  Conn.,  on  the  23d 
of  December,  1796.  He  was  of  Scotch  descent.  He  prepared  for  college  at 
an  academy  in  his  native  town,  and  entered  the 
sophomore  class  of  Yale  College  at  the  age  of  sixteen. 
On  his  graduation  in  1815  he  began  the  study  of 
medicine  in  the  office  of  Dr.  Thomas  Hubbard,  of 
Pomfret,  afterward  professor  of  surgery  in  the  Medical 
School  at  New  Haven.  In  1817  he  attended  lectures 
in  the  Medical  Department  of  the  University  of 
Pennsylvania,  and  entered  the  office  of  Dr.  John 
Syng  Dorsey,  then  professor  of  materia  medica  and 
anatomy  in  the  university.  In  1818  he  became  a 
member  of  the  resident  staff  of  the  Philadelphia 
Alnisliouse.  He  located  in  Philadelphia  and  began 
to  give  private  lectures  on  anatora3^  In  1825,  in 
co-operation  with  friends,  he  obtained  a  charter  for 
the  Jefferson  Medical  College,  in  which  he  occupied 
the  professorship  of  surgery  until  the  year  1838,  when 
the  professorships  were  all  vacated  by  the  trustees 
and  a  new  organization  formed,  from  which  Dr.  McClellan  was  excluded.  He  applied 
at  once  to  the  legislature  for  a  charter  of  another  college,  which  was  granted,  and 
"The  Medical  Department  of  Pennsylvania  College,"  at  Gettysburg,  was  established. 
The  lectures  were  commenced  at  Philadelphia  in  November,  1839.  At  the  close  of 
the  fourth  annual  course  of  lectures  the  faculty  resigned,  owing  to  pecuniary  com- 
pUcations,  and  Dr.  McClellan  retired  to  private  practice.  He  died  suddenly,  of 
perforation  of  the  colon,  on  the  8th  day  of  May,  1847. 

One  of  the  most  illustrious  surgeons  and  educators  of  our  period  was  a  private 
pupil  of  McClellan,  a  graduate  of  the  Jefferson  Medical  College,  and  his  successor 
to  the  chair  of  surgery — Dr.  Samuel  D.  Gross.  It  is  impossible  to  estimate  the 
vast  influence  of  Gross  upon  the  character  of  surgical  practice  during  his  long 
career  of  over  half  a  centurj^,  and  in  the  threefold  capacity  of  an  original  investi- 


FiG.  14.— George  McClellan  (1796- 
lcS47). 


INTRODUCTION. 


27 


Fig.  15. — Samuel  David  Gross 
(1S05-18S4). 


gator,  a  popular  teacher  in  many  schools,  and  an  accepted  authority  on  general 
surgery. 

Samuel  David  Gross  (1805-84)  was  born  near  Easton,  Pa.,  July  8th,  1805.    He 
received  a  classical  education  and  for  two  years  was  a  pupil  of  Dr.  George  McClellan, 
graduating  in  medicine  from  Jefferson  Medical  College  in  1828.    He  located  in  Phila- 
delphia, and  in  1830  published  a  work  on  "Diseases  _^ 
and  Injuries  of  the  Bones  and  Joints."     In  1833   he                #=^^*-^  — _  s&^-x 
became  demonstrator  of  anatomy  in  the  Medical  Col-              ^  '^'•'         ^ 
lege  of  Ohio,  and  in  1835  he  was  appointed  professor 
of  pathological  anatomy  in  the  Medical  Department 
of    the  Cincinnati  College.      His   lectures   were  the 
first  delivered  in  this  country  on  that  subject,  and 
resulted  in  the  preparation  of  a  work  on  the  "  Ele- 
ments of  Pathological  Anatomy,"  the  first  work  of 
the  kind  in  the  English  language.     In  1839  he  was 
appointed  professor  of  surgery  in  the  University  of 
Louisville,  Ky.,  and  in  1850  he  was  appointed  profes- 
sor of  surgery  in  the  Medical  Department  of  the  Uni- 
Tersity  of  the  City  of  New  York.     He  gave  but  a 
single  course  of  lectures  in  New  York,  and  returned 
to  his  former  position  in  the  Louisville  school.     In 
1865  he  was  appointed  professor  of  surgery  in  the  Jefferson  ^iledical  College,  Phila- 
delphia, from  which  he  retired  in  1882.    He  died  in  1884. 

Dr.  Isaac  M.  Hays  has  given  the  following  graphic  but  truthful  description  of 
Gross  as  a  man  and  as  a  teacher:  "Dr.  Gross's  magnetic  form  and  dignified 
presence,  his  broad  brow  and  intelligent  eye,  his  deep,  mellow  voice,  and  benig- 
nant smile,  his  genial  manner  and  cordial  greeting  remain  indelibly  impressed 
upon  the  memory  of  all  who  knew  him.  He  was  a  man  of  deep  mind  and  broad 
views,  and  he  was  a  model  of  industry  and  untiring  zeal.  .  .  .  His  style  was 
vigorous  and  pure.  It  is  safe  to  say  that  no  pre- 
vious medical  teacher  or  author  on  this  continent 
exercised  such  a  widespread  and  commanding  in- 
fluence. .  .  .  His  writings  have  been  the  most 
learned  and  volmninous  and  his  classes  among  the 
largest  that  have  ever  been  collected  in  this 
country." 

In  1837,  Rush  Medical  College,  of  Chicago,  was 
founded  by  Dr.  Daniel  Brainard.    This  was  the 
pioneer  medical  school  in  the  Northwest,  and  has 
alwa}^s  maintained  a  high  grade  of   surgical   in- 
„     ,„      ^      ,  struction. 

riG.  16.  —  Darnel  Bramard 

(1S12-1866).  Daniel  Brainard  (1812-66)  was  a  native  of  Wlrltes- 

borough,  N.  Y.    He  was  educated  at  the  public  schools  and  studied  medicine  in  the 
office  of  the  village  physician.     He  attended  two  courses  of  lectiues  at  the  Medical 


28  a:\ieric.\x  practice  of  surgery. 

College  at  Fairfield,  N.  Y.,  but  graduated  from  the  Jefferson  Medical  College,  Phila- 
delpliia,  in  1834.  He  began  to  give  lectures  on  anatomy  and  surgery  in  the  Oneida 
Institute,  and  in  1836  removed  to  Cliicago.  He  went  abroad  in  1839  and  returned 
in  1841,  when  he  was  appointed  professor  of  anatomy  in  the  University  of  St.  Louis, 
Mo.  He  took  an  active  part  in  organizing  the  Rush  Medical  College,  which  was 
chartered  in  1837,  and  opened  in  1843,  Brainard  occupying  the  chair  of  surgery. 
He  died  in  1866. 

Brainard  began  teaching  at  an  early  period  of  his  professional  career,  and 
thus  ciualified  himself  to  be  an  educator.  He  followed  the  trend  of  enterpris- 
ing young  men  of  that  day,  and  sought  fame  and  fortune  in  the  far  West,  locat- 
ing in  Chicago.  In  this  growing  city  and  future  metropolis  Brainard  found  an 
ample  field  for  the  exercise  of  his  talents  as  a  surgeon  and,  finally,  as  an  edu- 
cator. He  became  eminent  as  a  practical  surgeon,  and  in  the  establislmient  of 
Rush  iledical  College  he  found  his  opportmiity  as  a  teacher.  In  the  latter 
capacity  we  have  the  testimony  of  his  biographer  that :  "  As  a  teacher  he  stood 
without  a  rival." 

The  pioneer  teacher  of  surgery  in  the  extreme  South  was  Dr.  Warren  Stone 
(1808-72),  of  New  Orleans.  He  was  a  native  of  Vermont  and  studied  medicine 
under  Dr.  Amos  Twitchell,  one  of  the  most  famous  surgeons  of  that  day  in 
this  country.  He  took  his  medical  degree  at  Philadelphia  in  1825,  and  located 
in  Xew  Orleans.  He  was  connected  with  the  Medical  Department  of  the 
University  of  Louisiana  from  its  organization  in  1834.  During  the  first  and 
second  sessions  he  discharged  the  duties  of  demonstrator,  and  was  appointed 

surgeon  to  the  Charity  Hospital.  In  1836  he 
was  appointed  lecturer  on  anatomj^,  and  in 
1837  professor  of  that  branch,  at  the  same  time 
giving  the  lectui'es  on  surgery.  In  1839  anat- 
omj'  was  separated  from  sm'gerj^,  and  he  as- 
smned  the  full  duties  of  the  chair  of  surgery. 
For  upward  of  a  third  of  a  century  Stone 
taught  large  classes  of  students  and  exercised 
-  a  great  mfiuence  upon  the  practice  of  sm-gery. 
Gross  attributes  his  success  to  his  large  heart 
and  the  native  powers  of  his  mind,  strong  and 
•^^^-  .  ' '        well  poised. 

One  of  the  most  conspicuous  stirgeons  of  the 

Fig.    17.-A^arren    Stone    (1S07-        g^^^j      ^.j^^    ^^    ^^  ^^^.j  -q^j    ^q^j.   ^^   ^^^ 

187S).  '  . 

part  as  a  teacher  in  the  newly  organized  medical 
schools,  was  Dr.  Paul  F.  Eve.  He  was  a  native  of  Georgia,  a  graduate  of  the 
University  Medical  College,  Philadelphia,  and  later  an  attendant  upon  the 
lectures  and  practice  of  the  leading  surgeons  of  London  and  Paris.  He  began 
teaching  in  1832,  in  a  small  college  in  Georgia,  and  from  that  time  until  his 


INTRODUCTION.  29 

death  he  was  engaged  hi  giving  courses  of  lectures  on  surgery  in  a  large  number 

of  colleges.     On  his  final  settlement  in  Nashville,  Tenn.,  he  became  eminent  as 

a  practical  sm'geon.      As  an  instructor  he  was 

popular  and  had  flattering  offers  of  professorships  / 

of  surgery  in  the  older  colleges. 

Paul  Fitzsimmons  Eve  (1806-78)  was  a  native  , 

of  Augusta,  Ga.,  born  in  1806.  He  graduated  at 
Franklin  College,  Athens,  Ga.,  in  1826,  and  received 
his  medical  degree  from  the  University  of  Pennsyl- 
vania in  1828.  After  an  absence  in  Europe  of  three 
years,  he  returned  and  was  appointed  professor  of 
surgery  in  the  Medical  College  of  Georgia,  1832, 
recently  organized.  In  1850  he  was  appointed  to 
the  chair  of  surger}^  in  the  University  of  Louisville, 
as  successor  to  Gross,  but  retained  the  position  only 

one  session,  when  he  accepted  the  professorship  of       ^^^  is.— Paul  Fitzimmons  Eve 
surgery  in  the  University  of  Nashville.     In  1868  he  (1S06-187S). 

was  called  to  the  chair  of  surgery  in  the  Missouri  Med- 
ical College,  St.  Louis,  but  after  two  courses  of  lectures  he  returned  to  Nashville  and 
became  professor  of  clinical  and  operative  surgery  in  the  Nashville  Medical  College, 
then  being  organized.  He  had  invitations  to  accept  professorships  in  colleges  in  New 
York,  Philadelphia,  New  Orleans,  and  Memphis,  but  he  declined  them  and  remained 
in  Nashville  until  his  death  in  1878. 

The  founder  of  the  St.  Louis  Medical  College,  Missouri,  was  Dr.  Charles  A. 
Pope,  one  of  the  most  prominent  surgeons  of  the  West  at  that  period. 

The  establishment  of  a  medical  school  on  the  Pacific  Coast  was  effected  by 
Dr.  Cooper,  a  surgeon  having  a  wide  reputation  for  his  skill  as  an  operator  and 
his  enterprismg  spirit. 

We  cannot  farther  trace  the  progress  of  the  schools  which  were  to  educate  the 
future  surgeons  of  this  country  in  the  principles  of  scientific  surgery  and  to  illus- 
trate by  precept  and  practice  its  art,  But  must  notice  other  educational  forces 
which  have  more  or  less  effectively  impressed  a  national  stamp  upon  the  Ameri- 
can practice  of-  surgery.  First,  and  most  important,  is  the  development  of 
clinical  instruction  as  a  necessary  qualification  of  the  surgical  student  on  his 
graduation. 

The  value  of  clinical  instruction  was  recognized  and  efforts  were  made  to 
supply  it  by  the  medical  officers  of  the  Pennsylvania  Hospital,  as  early  as  1765. 
Cluiical  lectures  were  subsequently  given  in  the  almshouses  of  Philadelphia  and 
New  York,  and  later  in  the  New  York  Hospital  and  the  Massachusetts  General 
Hospital.  There  arose,  however,  two  serious  difficulties  that  obstructed  the 
progress  of  this  most  important  improvement  in  medical  education.  In  the  first 
place,  there  was  early  developed  an  intense  prejudice  on  the  part  of  lay  mana- 
gers of  hospitals  against  the  exposure  of  patients  to  the  observation  of  medical 


30  AMERiaiN  PRACTICE  OF  SURGERY. 

students  and  to  the  public  discussion  of  theii-  ailments.  It  was  believed  that 
the  inmates  would  regard  such  exposure  as  an  outrage  upon  common  decency 
and  universally  rebel  against  the  practice.  Happily,  experience  proved,  not  only 
that  patients  did  not  resent  such  treatment,  but  that  they  were  always  gratified 
with  being  selected  as  the  subjects  of  special  attention  and  study,  while  those 
who  were  passed  by  complained  of  neglect.  Again,  the  fact  developed  that 
those  hospitals  were  most  efficientlj^  and  carefully  supervised  in  the  medical  and 
surgical  service  where  the  visiting  staffs  gave  clinical  instruction.  The  result  of 
these  experiences  has  been,  not  only  the  removal  of  all  prejudices  against  clini- 
cal teaching  in  hospitals,  on  the  part  of  the  public,  but  a  disposition  of  man- 
agers to  encourage  the  medical  schools  to  use  the  service  for  the  purpose  of 
teaching.  In  the  second  place,  there  was  a  class  of  teachers  who  were  opposed  to 
hospital  attendance  by  medical  students  imtil  they  had  regularly  graduated  from 
the  schools.  It  was  alleged  that  midergraduates  could  not  be  benefited  by  at- 
tending lectures  on  subjects  which  they  could  not  by  any  possibility  imderstand, 
and  about  which  they  were  liable  to  obtain  false  views  that  would  prove  very  det- 
rimental m  practice.  Experience,  however,  established  the  fact  that  the  most 
thoroughly  qualified  graduate  in  both  teclmical  and  practical  knowledge  was  the 
student  who  had  received  clinical  instruction  from  the  outset  of  his  comse  of  study. 

Prior  to  1861  clinical  instruction  was,  however,  little  more  than  an  interest- 
ing incident  in  the  life  of  the  medical  student.  He  ^asited  the  hospitals  to  wit- 
ness an  advertised  operation  in  the  interval  of  lectures,  rather  for  the  relaxation 
and  excitement  which  the  occasion  afforded  than  for  any  positive  knowledge  he 
expected  to  acquire.  But  a  most  important  change  in  medical  education  was 
impending.  Clinical  teaching  was  to  become  an  essential  part  of  the  system  of 
instruction,  and  attendance  upon  its  lectures  was  no  longer  to  be  a  pastime,  but 
a  compulsory  duty  with  every  aspirant  for  graduation. 

This  advance  in  medical  education  was  largely  due  to  Dr.  James  R.  Wood,  of 
New  York.  On  the  reorganization  of  Bellevue  Hospital,  New  York,  the  visiting 
staff  of  physicians  and  surgeons,  imder  his  guidance  and  direction,  began  to  give 
systematic  courses  of  clmical  instruction  to  the  medical  students  of  the  several 
colleges.  The  staff  included  yomig  men  of  marked  ability,  ambitious  of  success 
as  teachers,  and  animated  with  that  genuine  entluLsiasm  which  stimulates  stu- 
dents to  high  endeavor.  Dr.  James  R.  Wood,  Dr.  William  H.  Van  Buren,  Dr. 
John  T.  Metcalfe,  Dr.  John  0.  Stone,  Dr.  Benjamin  W.  jMacready,  Dr.  Lewis  A. 
Sayre,  Dr.  George  T.  Elliott  were  lecturers  who  always  attracted  large  classes. 
So  popular  had  these  lectures  become  during  the  years  1855-60,  that  it  was  de- 
termined to  organize  a  chartered  medical  college,  in  which  clinical  instruction 
should  form  part  of  the  prescribed  course  of  study.  Bellevue  Hospital  Medical 
College  began  its  career  in  1861,  with  the  avowed  pin-pose  of  combining  didactic 
and  clinical  instruction.  The  popularity  of  the  clinical  teaching  in  the  hospital 
gave  tlie  new  college  immediate  success. 


INTRODUCTION.  31 

James  Rushmore  Wood  (1813-82)  was  born  in  the  city  of  New  York,  on  the  14th 
clay  of  September,  1813.  He  had  but  hmited  opportunities  for  education  at  the 
Friends'  Seminary,  in  New  York  City.  He  began  the  studj^  of  medicine  in  1829  with 
Dr.  David  L.  Rogers,  and  attended  his  first  course 
of  lectures  at  the  College  of  Physicians  and  Siu^- 
geons,  in  1831.  He  graduated  in  1834  from  the 
Medical  College  at  Castleton,  Vt.,  and  was  soon 
after  appointed  demonstrator  of  anatomy  in  that 
College.  He  located  in  New  York  and  rapidly  ad- 
vanced to  an  influential  position  in  the  practice 
of  surgery.  He  became  comiected  with  the  man- 
agement of  Bellevue  Hospital,  then  an  almshouse, 
and  in  1847  he  effected  a  complete  change  in  the 
organization  of  that  institution,  b}'  converting  it 
from  an  almshouse,  under  a  resident  physician,  into 
a  hospital,  with  its  visiting  and  resident  staffs  of 
physicians  and  surgeons,  and  under  the  direction 

Fic.  i9.-James  R.Wood  (1S13-1SS2).  °^  ^  '^^^^^^^^  ^oard.  He  began  a  systematic  course 
of  clinical  instruction,  which  drew  large  numbers 
of  students  to  its  wards  and  led  to  the  creation  of  the  Bellevue  Hospital  Medical 
College  in  1861.  Wood  was  appointed  professor  of  operative  surgery  and  siu-gical 
pathology  in  the  new  school,  a  position  which  he  held  upward  of  fifteen  years,  and 
on  retiring  was  appointed  emeritus  professor.     He  died  in  1882. 

Dennis,  the  biographer  of  Wood,  states  that  he  "was  foremost  in  the  view 
that  medicine  is  a  science  pre-eminently  of  demonstration  as  well  as  of  observa- 
tion, and  it  was  the  union  of  clinical  and  didactic  teaching  that  in  his  opinion 
best  attained  the  object  of  medical  education." 

Hospital  instruction  in  the  practice  of  surgery  has  become  increasingly  im- 
portant in  these  later  years,  when  anesthesia  and  antisepsis  have  given  to  the 
technique  of  operations  a  scientific  precision,  even  to  the  minutest  details  of  the 
preparation  of  the  patient,  the  operator,  his  assistants,  the  room,  the  appliances, 
the  administration  of  the  ansesthetic,  the  immediate  aid  of  the  surgeon,  and, 
finally,  the  preparation  and  application  of  the  permanent  dressings.  The  high- 
grade  technical  operator  regards  each  of  these  innumerable  details  as  vitally 
essential  to  the  success  of  the  operation.  But  it  is  impossible  to  gain  the  requi- 
site expertness  in  the  manipulation  of  these  complex  details  except  under  the 
conditions  which  are  enforced  in  a  modern  hospital.  The  hospitals  of  this  coun- 
try, therefore,  now  so  numerous  and  well  equipped,  have  become  essential  fac- 
tors in  the  education  of  surgeons  for  practical  duties.  Hundreds  of  surgeons 
graduate  annually  from  our  hospitals,  fully  c^ualified  bj^  education  and  practice 
to  undertake  the  most  responsible  duties  of  their  profession. 

But  the  modern  hospital  not  only  serves  as  a  school  for  perfecting  the  young 
surgeon  during  the  period  of  his  education  in  the  manual  or  art  of  surgery,  but 
it  supplies  conditions  nowhere  else  obtainable,  which  enable  the  surgeon  to  apply 


32  M'lERICAN  PRACTICE  OF  SURGERY. 

those  arts  in  practice  with  almost  absolute  success.  In  other  words,  the  modern 
well-equipped  hospital  is  essential  to  the  highest  degree  of  success  in  the  practice 
of  surgery,  whatever  may  be  the  skill  and  experience  of  the  individual  surgeon. 
Within  the  walls  of  thousands  of  hospitals  in  this  country  are  found  ready  and 
awaitmg  his  order  every  condition,  thing,  or  circumstance  which  the  surgeon 
can  possibly  in  any  emergency  require  for  successful  practice.  And  these  hos- 
pitals are  increasing  at  a  rate  that  positively  insures  to  every  communitj^  the 
opportunity  of  having  every  variety  of  disease  or  injury,  amenable  to  surgical 
treatment,  immediately  placed  under  conditions  most  favorable  for  recovery. 
Not  only  are  public  hospitals  increasing  in  such  vast  numbers,  but  on  every 
hand  surgeons  are  establishing  their  own  private  hospitals,  equipped  with  every- 
thing required  for  the  most  successful  work.  To  these  should  be  added  the  in- 
creasing number  of  large  priA^ate  corporate  hospitals,  where  operations  are  daily 
performed  by  the  score,  with  an  accuracy  in  all  the  details  of  the  procedure 
comparable  to  that  performed  by  instrimients  of  precision.  Large  nimibers  of 
these  hospitals  are  devoted  to  special  classes  of  diseases,  as  the  eye  and  ear,  the 
throat  and  nose,  the  genito-urinary  apparatus,  and  in  each  will  be  found  the 
highest  grade  of  surgical  practice.  Some  of  these  corporate  hospitals  are  de- 
voted to  general  siu^gical  practice,  where  operations  are  performed  on  a  vast 
scale  and  with  marvellous  success.  Finall}-,  there  are  corporate  hospitals  which 
combine  not  only  all  the  specialties  with  general  surgery,  but  they  are  supplied 
with  laboratories  for  biological  and  pathological  investigations,  and  appliances 
for  every  form  of  mechanical  and  instrumental  treatment.  These  great  institu- 
tions, which  are  rapidly  increasing  in  various  parts  of  the  country,  indicate  that 
the  time  is  approaching  when  the  American  practice  of  surgerj',  in  all  its  details, 
will  be  established  on  strictly  scientific  principles. 

"The  Training-school  for  Nurses"  in  the  modern  hospital,  inaugurated  in 
1872  in  Bellevue  Hospital,  New  York,  is  a  factor  in  the  successful  practice  of 
surgerj^,  the  value  of  which  it  is  quite  impossible  to  estimate.  That  these  schools 
have  revolutionized  practice  is  the  universal  testimony  of  both  phj-sicians  and  sur- 
geons. Only  the  operator  himself  can,  from  his  individual  experience,  appre- 
ciate at  its  full  value  the  assistance  of  the  expert  and  reliable  nurse,  who  pre- 
pares his  patient,  deftly  meets  every  want  and  emergencj'  during  the  operation, 
and  during  the  critical  hours  or  days  or  weeks  of  convalescence  faitlifully  watches 
every  s}Tnptom,  rightly  interprets  its  meanmg,  whether  for  good  or  for  evil,  and 
promptly  and  mtelligently  applies  the  prescribed  remedial  measure.  So  essen- 
tial has  the  trained  nurse  become  to  success  in  the  practice  of  surgery  in  this 
country  that  every  hospital,  however  small,  has  its  corps  of  nurses,  and  no  sur- 
geon will  operate  without  their  aid  when  it  can  be  obtained. 

It  is  often  alleged  that  our  system  of  medical  education  is  very  defective  in 
the  advantages  of  pathological  research  which  are  afforded  by  large  inuseums. 


INTRODUCTION.  33 

The  few  morbid  specimens  which  individual  surgeons  were  able  to  save  in  their 
practice  threw  but  little  light  on  obscure  questions  of  pathology,  and  it  has  been 
believed  that  only  in  the  great  museums  of  Europe  can  such  studies  be  ade- 
quately pursued.  Efforts  to  supply  this  want  have  been  made  by  individual 
surgeons,  notably  by  Dr.  James  R.  Wood,  of  New  York,  and  Dr.  Thomas  D.  Miit- 
ter,  of  Philadelphia.  But  there  is  much  truth  in  the  conclusion  of  Hamilton, 
who  consulted  all  of  the  great  museums  of  the  world,  while  preparing  his  work 
on  "Fractures  and  Dislocations,"  to  determine  positively  doubtful  questions: 
"  Nothing  is  more  unreliable  than  the  testimony  furnished  by  cabinet  specimens 
whose  clinical  history  is  wholly  unknown,  and  in  reference  to  which  in  many 
cases  it  is  impossible  to  say  whether  their  present  condition  was  du  e  to  trauma- 
tism before  or  after  death,  or,  mdeed,  whether  it  was  not  due  to  some  long-pre- 
existing pathological  cause." 

In  place  of  the  museum  the  colleges  have  now  their  well-equipped  labora- 
tories and  their  courses  of  instruction  in  the  closely  allied  branches  of  a  complete 
medical  education,  viz.,  biology  and  pathology.  In  these  departments  the  stu- 
dent has  immediate  access  to  the  healthy  and  morbid  specimens,  so  freshly 
prepared  as  to  be  wellnigh  living  in  their  accuracy  of  illustration,  with  necessary 
demonstrations  of  all  doubtful  questions  by  the  instructor.  As  a  means  of 
firmly  implanting  in  the  student's  memory  useful  practical  facts,  the  present 
method  of  teaching  these  subjects  in  the  laboratory  has  many  and  important 
advantages  over  the  mere  study  of  museum  specimens. 

The  literature  of  a  profession  is  not  only  a  safe  guide  to  the  estimation  of  the 
scientific  spirit  which  inspires  its  practice,  but  it  is  an  important  educational 
force  in  developing  the  character  of  the  coming  generations  of  practitioners.  In 
this  view  the  literature  of  American  surgery  deserves  proper  estimation.  Its 
development  has  necessarily  kept  pace,  both  in  quantity  and  quality,  with  the 
progress  of  the  schools  in  raising  the  standard  of  medical  educational  qualifica- 
tions. From  one  book  in  a  quarter  of  a  century  it  has  increased  to  a  score  of 
books  in  one  year,  and  from  one  serial  publication  it  has  multiplied  to  fifty  peri- 
odicals. It  began,  both  in  book  and  in  serial  form,  during  the  last  quarter  of  the 
eighteenth  century,  and  was  for  a  considerable  period  but  little  more  than  a 
transcript  of  British  surgical  literature.  As  such,  however,  it  shows  a  wise  and 
judicious  discrimination  on  the  part  of  authors  to  meet  the  wants  of  the  practis- 
ing surgeon.  But,  in  time,  books  and  even  articles  were  published,  which  on  ac- 
coiuit  of  their  originality  were  epoch-making  in  their  influence. 

The  author  of  the  first  surgical  work  was  Dr.  John  Jones,  of  New  York,  and 
it  was  written  to  meet  the  emergency  which  confronted  the  medical  profession  at 
the  opening  of  the  war  of  the  Revolution.  Dr.  Jones  was  well  qualified  for  this 
task.  He  had  been  educated  in  the  British  and  French  schools,  had  practised 
surgery  with  great  success  in  New  York  for  a  score  of  years,  had  given  full 

VOL.  I. — 3 


34  AMERICAN  PRACTICE  OF  SURGERY. 

courses  of  lectures  on  surgerj-  in  the  ]\Iedical  Department  of  King's  College  for 
seven  j'ears.  His  special  qualification  for  this  task  gi-ew  more  directly  out  of 
his  experience  in  the  war  on  the  Canadian  frontier,  between  the  English  and 
French,  in  1755,  where  he  won  distinction  as  a  surgeon.  The  remarkable  case  of 
the  French  general,  Baron  de  Dieskau,  who  was  woimded  and  taken  prisoner 
and  placed  in  charge  of  Jones,  illustrates  his  skill  as  a  military  surgeon.  The 
general  was  wounded  in  the  hip,  in  the  thigh,  in  both  knees,  and  through  the 
pelvis,  the  latter  wound  inA^olving  the  urinary  bladder,  so  that  urine  escaped 
from  the  wound  of  entrance  and  of  exit.  Though  the  conditions  under  which  the 
patient  was  treated  were  most  imfavorable,  he  recovered  so  as  to  be  able  to  re- 
turn to  Eiuope. 

Dr.  Jones's  work  was  entitled  "Plain,  Concise,  Practical  Remai-fcs  on  the 
Treatment  of  Wounds  and  Fractures."  It  was  printed  at  Xew  York,  in  1775,  but 
in  1776  a  second.edition  was  issued  at  Philadelphia,  to  which  was  added  the 
popular  work  of  Van  Swieten  on  "  The  Diseases  Incident  to  Armies  and  Qimshot 
^Youncls."  The  work  was  what  its  title  annoimced — smiply  plain,  concise,  and 
practical  remarks  on  all  that  at  that  time  was  known  of  militarj'  surgery.  The 
merits  of  the  book  lie  in  its  adaptation  to  the  wants  of  the  surgeons  of  the  Con- 
tinental Army,  few  of  whom  had  any  useful  surgical  knowledge,  theoretical  or 
practical.  The  only  works  on  surgery  at  the  time  were  meagre  treatises,  and 
even  these  were  accessible  to  but  few.  The  appearance  of  Dr.  Jones's  work,  in 
small  manual  form,  at  the  very  beginning  of  the  war,  was  an  achieA'ement  of 
national  importance.  Dr.  David  Ramsay,  a  contemporarj'  medical  historian, 
says  this  work  ''will  long  remain  a  monument  both  of  professional  skill  and 
patriotism  of  its  author," 

Notwithstandmg  the  progress  of  the  schools  and  the  great  impulse  that  had 
been  given  to  the  study  of  scientific  surgery  by  Himter's  teachings,  especially 
among  v^ierican  students,  nearly  forty  years  elapsed  after  the  issue  of  Dr. 
Jones's  work  <  before  another  native  surgical  treatise  appeared.  In  1813  Dr. 
John  Syng  Dorsey,  of  Philadelphia,  published  a  systematic  work,  entitled  "  Ele- 
ments of  Surgery,"  in  two  volumes,  8vo,  which  reached  a  second  edition  in  1818, 
and  a  third  in  1823.  It  was  a  work  of  great  merit  for  that  period,  as  it  faithfuUy 
illustrated  the  practice  of  British  surgery,  but,  in  addition,  it  gave  publicity  to 
Physick's  surgical  teachings,  which  might  otherwise  have  been  lost  to  surgeons. 
The  value  of  this  work  was  recognized  by  the  Edinburgh  school,  which  adopted 
it  as  a  text-book. 

In  1824  appeared  ''  The  Institutes  and  Practice  of  Surgery,"  by  Prof.  William 
Gibson,  professor  of  surgery  in  the  Medical  Department  of  the  University  of 
Pennsylvania,  in  two  volumes.  It  was  announced  to  be  "  outlines  of  a  com^se  of 
lectures,"  and  "published  at  the  request  of  students  who  want  a  text-book"; 
the  "work  must  be  considered  as  a  mere  outline  of  the  lectures,  to  be  filled  up 
by  numerous  ilkistrations,  chiefly  models,  morbid  preparations,  magnified  draw- 


INTRODUCTION.  35 

ings,  and  imitations  on  the  dead  subject.  The  last  two  modes  of  instruction  I 
consider  pecuUarly  my  own."  That  this  work  was  well  received  we  learn  from 
the  preface  of  the  second  edition,  which  appeared  in  1827 :  "  The  praises  which 
have  been  bestowed  on  the  work  by  European  and  American  critics,  though  far 
beyond,  in  many  instances,  any  merit  I  should  be  entitled  to  claim,"  etc.  In 
the  preface  to  the  third  edition,  which  appeared  in  1833,  the  author  says:  "This 
work  has  been  pronotmced  by  hypercritics  a  book  on  the  practice  of  medicine." 
He  adds:  "A  greater  compliment  could  not  have  been  paid  to  it,  and  yet  it 
argues  a  very  narrow  view  on  the  part  of  those  who  strive  to  affix  limits  to 
sciences  which  blend  and  often  unite  in  every  possible  way."  He  defends  this 
featm-e  of  his  work  on  the  groimd  that  practitioners  in  this  country  must  prac- 
tise both  medicine  and  surgery.  That  the  work  was  well  adapted  to  the  wants 
of  the  profession  is  evidenced  by  the  appearance  of  a  fourth  edition  in  1835  and 
a  fifth  edition  m  1838. 

In  1859  appeared  "A  System  of  Surgery,"  by  Prof.  S.  D.  Gross,  professor  of 
surgery  in  Jefferson  Medical  College,  in  two  large  volumes.  The  author  says: 
"The  object  of  this  work  is  to  furnish  a  systematic  and  comprehensive  treatise 
on  the  science  and  practice  of  surgery,  considered  in  the  broadest  sense.  .  .  . 
My  aim  has  been  to  embrace  the  whole  domain  of  surgery  and  to  allot  to  every 
subject  its  legitimate  claim  to  notice  in  the  great  family  of  external  diseases  and 
accidents."  He  continues:  "It  may  safely  be  affirmed  that  there  is  no  topic, 
properly  appertaining  to  surgery,  that  will  not  be  found  to  be  discussed  to  a 
greater  or  less  extent  in  these  volumes."  This  system  of  surgery  was  a  work  of 
very  unequal  merit,  owing  to  the  treatment  of  such  a  wide  range  of  subjects  by 
a  single  author,  but  it  became  the  text-book  of  the  schools  and  retained  that 
position  through  many  editions. 

Although  the  works  of  several  British  surgical  authors  appeared  and  were 
republished  in  this  country  during  this  period,  the  native  works  of  Dorsey,  Gib- 
son, and  Gross  were  generally  accepted  as  text-books  and  guides  to  American 
practice.  In  addition  to  these  works  on  general  surgery,  several  treatises  on 
special  branches  of  practice  were  published  and  deserve  notice.  As  the  authors 
of  these  works  were  surgeons  educated  in  the  home  schools,  the  text  illustrates 
the  stage  of  progress  in  the  practice  of  these  specialties  to  which  they  had  at- 
tained. 

In  1851  Gross  published  a  work  entitled  "A  Practical  Treatise  on  the  Dis- 
eases and  Injuries  of  the  Urinary  Bladder,  the  Prostate  Gland,  and  the  Urethra." 
This  treatise  has  the  merit  of  being  the  first  complete  work  in  the  English  lan- 
guage on  these  organs.  At  the  time  of  its  appearance  several  British  surgeons 
had  written  monographs  on  these  subjects,  but  no  one  had  ventured  to  cover 
the  whole  field  as  did  the  American  author.  The  only  other  accessible  complete 
treatise  of  the  kind  was  that  of  the  French  authority,  Civiale.  In  his  preface 
Gross  states  that  his  sole  object  "has  been  to  furnish  a  monograph  on  the  dis- 


36  AMERICAN  PRACTICE  OF  SURGERY. 

eases  and  injuries  of  the  urinar}^  organs  that  should  be^Yorthy  of  the  favorable 
consideration  of  his  professional  brethren  and  of  the  present  state  of  medical 
science  in  this  country."  This  work  greatly  improved  the  treatment  of  genito- 
xu'inary  diseases  and  laid  the  foundation  of  that  specialty  as  it  is  now  recognized 
in  the  schools. 

In  1860  Dr.  Frank  H.  Hamilton  published  his  work,  entitled,  "  A  Practical 
Treatise  on  Fractures  and  Dislocations."  It  was  the  first  treatise  on  these  sub- 
jects written  in  the  English  language  and  supplied  a  pressing  want.  Hamilton 
was  amply  qualified  for  the  task  which  he  undertook.  He  had  been  a  teacher 
of  surgery  from  his  graduation,  in  several  colleges,  and  had  a  large  experience  as 
an  expert  witness  in  suits  against  physicians,  so  frequent  at  that  time.  The 
subject  of  litigation  was  usually  malpractice  m  the  treatment  of  fractures.  The 
great  diversity  of  opinions  among  surgeons  at  these  trials  and  the  entire  absence 
of  any  reliable  authority  was  the  incentive  that  prompted  him  to  undertake  the 
investigations  which  form  the  basis  of  this  treatise.  He  was  indefatigable  in  the 
pursuit  of  facts,  and  endeavored,  by  experiments  and  personal  visits  to  patholog- 
ical museums  in  this  country  and  Europe,  to  verify  every  statement  and  judi- 
cially establish  every  opinion  which  he  should  record. 

Frank  Hastings  Hamilton  (1813-86)  was  born  at  Wilmington,  Vt.,  Septem- 
ber 10th,  1813.  He  received  his  classical  education  at  Union  College,  Schenectady, 
,N.  Y.,  and  graduated  in  medicine  from  the  Medical  f,.^Sr 

Department  of  the  University  of  Pennsylvania  in 
1833.    He  located  at  Auburn,  N.  Y.,  but  removed  to  e 

Rochester,  and  in  1848  to  Buffalo,  and  in  1862  to  New  ^^^  ""^"^ 

York.    He  gave  courses  of  lectures  on  surgery  at  the  ,  ^  i 

Pittstield  Medical  School,  Mass.,  and  at  the  Geneva 
Medical  College,  N.  Y.  On  the  establishment  of  the 
Medical  Department  of  the  University  of  Buffalo  he 
was  appointed  professor  of  surgery,  a  position  which 
he  held  until  his  removal  to  New  York.  He  gave  courses 
of  lectures  in  the  Long  Island  Medical  College,  and  was 
appointed  professor  of  the  specialty,  "Fractures  and 

Dislocations,"  in  the  Bellevue  Medical  College,  New   ^^^   ''  c^ 

York,  in  1862.  Soon  after,  he  enlisted  as  brigade  sur-  Fig  20 —Frank.  Hastmgb  Hamii- 
geon  and  served  in  the  Army  of  the  Potomac,  acting  as  on  (       -       ). 

medical  inspector  in  1863,  but  ill  health  compelled  his  resignation..  In  1875  he  re- 
signed his  professorship  in  the  Bellevue  Medical  College.  He  died  in  New  York, 
August  11th,  1886. 

In  the  preface  to  the  seventh  edition  of  the  treatise,  published  in  1884,  the 
author  reveals  in  apologetic  terms  the  conscientious  and  judicial  spirit  in  which 
the  work  is  written :  "  From  the  beginning  of  his  studies  the  author  has  found 
one  of  his  most  difhcult  labors  in  attempting  to  eliminate  from  the  branch  of 
science  which  he  has  undertaken  to  teach  the  numerous  'false  facts'  or  im- 


INTRODUCTION.  37 

reliable  statements  derived  from  these  several  som-ces,  and  this  must  be  accepted 
as  his  apology  for  his  repeated  expressions  of  scepticism  in  reference  to  testimony, 
some  of  Avhich  has  been  accepted,  as  is  believed  without  sufficient  examination, 
by  Avriters  whose  opinions  might  be  regarded  as  of  more  value  than  his  own." 

Its  thoroughly  scientific  character,  its  accurate  historical  review,  its  large 
range  of  well-digested  facts,  its  careful  analysis  of  current  theories  and  opinions, 
and  its  pure  English  style  placed  it  at  once  among  the  classics  of  surgical  litera- 
ture. Although  out  of  print,  it  still  maintains  its  position  among  surgeons  as 
the  most  reliable  authority  in  the  English  language  on  fractures  and  dislocations. 

Hamilton's  work  led  to  the  establishment  of  a  "  chair  of  fractures  and  dis- 
locations" in  the  Bellevue  Hospital  Medical  College. 

In  1861  Dr.  Freeman  J.  Bumstead,  of  New  York,  published  a  work,  entitled, 
"Pathology  and  Treatment  of  Venereal  Diseases."  The  object  of  the  author  was 
to  furnish  the  student  a  full  and  comprehensive  treatise  on  the  venereal  dis- 
eases, and  the  practitioner  a  plain,  practical  guide  in  their  treatment.  The 
work  of  Bumstead  was  received  with  great  favor,  and  created  so  much  interest 
in  venereal  diseases  that  the  medical  schools  began  to  introduce  courses  of  in- 
struction on  this  subject  as  a  specialty.  Several  editions  of  this  work  appeared, 
and  during  the  lifetime  of  the  author  it  maintained  its  position  as  the  most  com- 
plete and  reliable  work  on  venereal  diseases  in  the  English  language. 

■  During  this  period  large  numbers  of  monographs  appeared  on  surgical  sub- 
jects, some  of  which  were  of  a  high  order  of  merit  and  greatly  improved  methods 
of  practice.  Several  of  these  publications  will  be  noticed  in  other  sections  of  this 
paper. 

In  his  historical  sketch  of  the  medical  literature  and  institutions  of  this  coun- 
try, Dr.  John  S.  Billings,  an  eminent  authority,  remarks :  "  Since  the  year  ISOO 
medical  journalism  has  become  the  principal  means  of  recording  and  communi- 
cating the  observations  and  ideas  of  those  engaged  in  the  practice  of  medicine, 
and  has  exercised  a  strong  influence  for  the  advancement  of  medical  science  and 
education."  That  the  medical  profession  of  this  country  has  improved  this 
method  of  advancement,  is  shown  by  his  summary  of  medical  journals  published 
down  to  1876,  the  number  being  one  hundred  and  ninety-five,  including  reprints 
of  foreign  journals,  making  in  all  sixteen  hundred  and  thirty-seven  volumes.  It 
is  the  universal  testimony  of  surgeons  that  they  have  derived  more  benefit  in  the 
details  of  practice  from  the  current  information  furnished  by  medical  journals 
than  from  text-books  of  surgery. 

The  growth  of  medical  libraries  in  this  country  is  another  striking  feature  of 
the  evolutionary  process  by  which  the  practice  of  surgery  has  advanced  to  a 
more  and  more  nearly  perfect  state  of  development.  In  these  latter  days  there 
is  a  flood-tide  of  surgical  publications.  The  pioneer  surgeons  complamed  that 
they  had  no  books  to  consult  and  had  to  rely  on  their  own  unaided  judgment  in 
the  emergencies  of  practice;    but  modern  surgeons  have  such  a  surplus  that 


38  AMERICAN  PRACTICE  OF  SURGERY. 

they  are  compelled  to  adopt  the  co-operative  plan,  so  popular  in  business  circles, 
of  forming  libraries  capable  of  accumulating  all  of  the  current  surgical  literature, 
for  the  use  and  common  good  of  surgeons  of  every  grade.  These  libraries  are 
becoming  more  and  more  the  great  centres  of  education  of  the  entire  profession, 
and  their  influence  in  elevating  the  grade  of  practice  becomes  daily  more  and 
more  evident.  There  are  now  164  medical  libraries  in  the  United  States,  contain- 
ing a  total  of  912,330  volumes. 

With  this  review  of  the  development  of  the  educational  qualifications  of 
American  surgeons,  we  are  prepared  to  estimate  the  value  of  that  education,  as 
illustrated  in  the  performance  of  the  practical  duties  of  their  profession.  We 
can  select  only  the  more  important  questions  in  the  practice  of  British  surgery 
at  the  beginning  of  our  period,  and  consider  their  treatment  by  American  sur- 
geons. This  examination  will  bring  prominently  into  view  the  special  charac- 
teristics of  the  American  practice  of  surgery. 

Mr.  Erichssen,  in  his  "Impressions  of  American  Surgery,"  already  referred 
to,  remarks :  "  The  bent  of  the  mind  of  the  American  surgeon  is,  like  ours,  prac- 
tical rather  than  scientific."  There  is  ample  proof  that  the  achievements  of 
American  surgeons  are  to  be  fomid  in  the  field  of  practice  rather  than  in  the 
laboratory.  This  fact  is  not  due  to  a  lack  of  interest  on  the  part  of  American 
surgeons  in  the  truths  of  science  nor  to  failure  to  appreciate  their  value  when 
applied  to  practice,  but  rather  to  the  social  conditions  under  which  the  surgeon 
begins  his  career.  The  commmiity  in  which  he  locates  is  yoimg,  compared  with, 
those  of  the  old  world,  and  professional  and  business  success  is  popularly  esti- 
mated by  those  activities  which  have  the  greatest  publicity.  \Vliatever  may  be 
the  qualifications  of  a  graduate  of  one  of  our  medical  schools  for  a  successful 
career  as  a  scientist,  if  he  has  had  the  training  of  a  practical  surgeon  in  a  modern 
hospital,  he  will  almost  invariably  be  so  fascinated  by  the  glamour  of  operations 
as  to  subordinate  science  to  practice. 

The  American  practice  of  surgery  has  always  been  characterized  by  self- 
reliance  and  resourcefulness.  This  has  been  due  in  part  to  the  more  limited 
means  and  agencies  at  the  command  of  the  practitioner  in  this  country,  and  in 
part  to  the  adventurous  spirit  which  has  always  inspired  every  department  of 
American  activity.  Thousands  of  surgeons  have  been  compelled  to  practise  their 
profession  far  removed  from  access  either  to  the  aid  or  the  advice  of  a  com- 
petent surgeon  or  to  necessary  instruments  and  remedial  agents.  Many  new  and 
difficult  operations  have  been  performed  under  these  conditions  and  with  a  re- 
markable degree  of  success.  It  is  true  that  operations  under  such  circumstances 
are  liable  to  have  no  scientific  value,  unless  they  incidentally  suggest  or  reveal 
important  facts  hitherto  unknown ;  but  they  do  demonstrate,  as  no  other  method 
can,  the  boldness  and  daring  of  the  operator  and  his  mental  equilibrium  and  re- 
sources in  emergencies.    A  review  of  the  practice  of  surgery  in  the  early  periods 


INTRODUCTION.  39 

of  our  national  history  proves  that  these  attributes  have  always  been  dominant 
features  of  the  qualifications  of  American  surgeons. 

As  we  have  already  stated,  the  practice  of  surgery  in  this  country  illustrated 
the  progress  and  growth  of  British  surgery  transplanted  to  a  virgin  soil.  Edu- 
cated in  all  the  traditions  of  the  foreign  schools,  but  unhampered  by  them  in  his 
practice  and  usually  left  to  his  own  resources,  the  pioneer  American  surgeon  was 
compelled  to  resort  to  new  and  untried,  and  even  unheard-of  methods,  to  meet 
emergencies.  On  this  account  the  practice  of  surgery  in  this  country  has  neces- 
sarily been  characterized  by  a  freedom  from  arbitrary  and  often  impracticable 
rules,  which  have  a  controlling  force  with  surgeons  of  the  older  countries.  It 
has  been  very  frequenty  asserted  that  this  freedom  from  technical  rules  in  the 
practice  of  surgery  is  liable  to  result  in  dangerous  adventures  on  the  part  of 
the  surgeon,  quite  incompatible  with  judicious  conservatism.  But  such  has  not 
been  our  experience ;  on  the  contrary,  this  very  freedom  has  developed  such  an 
overpowering  sense  of  personal  responsibility  that  the  surgeon  has  proceeded 
with  a  degree  of  caution  the  equivalent  of  true  conservatism. 

The  evolution  of  the  practice  of  American  surgery  necessarily  kept  pace  with 
the  progress  of  the  medical  schools  m  developing  the  educational  qualifications 
of  the  future  surgeons  of  the  country.  Prior  to  the  year  1800,  the  three  pioneer 
medical  colleges  had  graduated  too  few  students  to  have  exerted  any  marked 
influence  upon  the  profession  at  large,  especially  in  regard  to  the  practice  of  sur- 
gery. But  during  the  first  quarter  of  the  nineteenth  century  the  number  of  med- 
ical colleges  rapidly  increased  and  the  grade  of  teaching  greatly  improved.  The 
result  appears  in  the  increased  activity  of  surgeons  in  performing  formidable 
operations  and  the  independence  which  characterized  their  departure  from  rules 
established  by  the  foreign  schools.  It  is  during  this  period  that  we  begin  to  trace 
the  line  of  cleavage  between  Aiiierican  and  European  surgery,  and  from  this  time 
we  more  and  more  frequently  meet  the  word  "American"  in  surgical  literature, 
in  connection  with  new  inventions  and  methods  of  operation.  It  was,  therefore, 
during  the  early  years  of  the  nineteenth  century  that  the  evolution  of  what  may 
properly  be  termed  "the  American  practice  of  surgery"  began  to  appear,  and  it 
is  from  that  period  we  shall  begin  to  trace  its  development  and  illustrate  its  dis- 
tinctive features. 

The  treatment  of  aneurism  was  a  subject  of  absorbing  interest  to  British  sur- 
geons at  the  close  of  the  eighteenth  century.  Hunter  had  perfected  Anel's  method 
of  ligatuig  the  artery  on  the  proximal  side  of  the  tumor,  and  had  established  the 
following  principles:  1.  The  ligature  should  be  applied  at  a  sufficient  distance 
from  the  tumor  to  insure  a  healthy  condition  of  the  artery.  2.  The  artery  should 
not  be  disturbed  more  than  is  necessary  to  secure  the  passage  of  the  ligature. 
3.  One  ligature  is  sufficient.  4.  The  wound  should  be  healed  by  first  intention 
as  far  as  possible. 


40  AMERICAN  PRACTICE  OF  SURGERY. 

Hunter's  operation  was  performed  with  indifferent  success  by  British  sur- 
geons, accordmg  to  Home,  owing  to  modifications  which  they  made  of  the  pro- 
cedure of  the  original  operator.  The  surgeons  of  the  continent  ignored  this 
method  of  treating  aneurism,  cliiefiy  because  it  liad  a  British  origin.  But  there 
was  present  at  Hunter's  first  operation  a  yoimg  American  surgeon  from  the  city 
of  New  York,  who  thoroughly  comprehended  the  opinions  of  the  operator,  and 
appreciated  at  its  full  value  the  immense  importance  of  the  operation.  Dr. 
Wright  Post  was  a  pupil  of  a  member  of  the  staff  of  St.  George's  Hospital  at  the 
date  of  Hunter's  first  operation,  which  was  performed  in  that  hospital  in  Decem- 
ber, 1785.  Post  returned  to  New  York  in  1786,  and  soon  took  a  high  rank  as  a 
teacher  of  anatomy  and  surgery.  The  treatment  of  aneurism  by  the  new  opera- 
tion was  evidently  the  theme  of  some  of  his  lectures,  for  Mott,  his  most  eminent 
student,  says  Post  expressed  the  opmion  that  not  only  one  carotid  artery  might 
be  ligated  for  aneurism  safely,  but  that  both  might  be  interrupted  by  ligature 
on  the  same  person  without  harm,  long  before  Astley  Cooper  operated  on  that 
artery. 

Post's  first  operation  was  the  ligation  of  the  femoral  artery  for  aneurism,  in 
1796.  The  patient  had  a  femoral  aneurism  caused  by  a  wound  of  the  artery 
fifteen  years  previously.  The  precise  location  of  the  aneurism  is  not  given,  nor 
the  point  at  which  the  ligature  was  applied.  The  patient  recovered  in  the  usual 
time  and  the  tumor  gradually  duninished  until  it  was  reduced  to  a  size  not  ex- 
ceeding one  inch  in  diameter.  An  interesting  feature  of  the  case  was  a  continu- 
ance of  the  pulsation  of  the  tmnor,  which  Post  attributed  to  the  increased  size 
of  the  anastomosing  vessels  due  to  the  long  continuance  of  the  aneurism.  The 
limb  became  as  useful  as  it  was  before  the  accident. 

This  was  the  first  operation  for  the  cm-e  of  anevirism  on  the  Hunterian  prin- 
ciple in  this  coimtry,  and  the  beginning  of  the  operator's  career  as  the  practical 
exponent  of  the  Hmiterian  method  of  treating  aneurism. 

The  first  operation  of  ligating  the  common  carotid  for  aneurism  in  this  coun- 
try was  performed  by  Post,  January  9th,  1813.  The  tmnor  was  situated  below 
the  angle  of  the  jaw  on  the  right  side,  and  measured  six  inches  in  length,  four 
inches  in  breadth,  and  two  mches  in  height.  Two  ligatures  were  applied  and  the 
artery  was  divided  between  them.  The  case  did  well  and  was  discharged  at  the 
end  of  four  months.  The  patient  returned  in  two  months,  the  timior  being  large 
and  fluctuating.  It  soon  after  opened  and  there  was  a  hemorrhage  of  thirty 
oimces.  It  opened  in  a  second  place  and  discharged  pus  and  blood;  severe 
hemorrhage  occurred  several  times,  and  once  the  patient  was  thought  to  have 
lost  two  quarts.  Extensive  suppuration  occurred  at  the  site  of  the  aneurism, 
but  the  patient  fuially  recovered. 

The  peculiarities  of  this  operation  were:  (1)  The  passage  of  two  ligatures 
around  the  artery,  about  three-quarters  of  an  mch  apart;  (2)  the  passage  of  the 
ligature  through  the  artery  to  prevent  its  slipping  from  the  end  of  the  cut  ar- 


INTRODUCTION.  41 

tery,  as  recommended  by  Dionis  and  Cline;  and  (3)  the  division  of  the  artery 
between  the  ligatures.  The  danger  of  hemorrhage  from  the  sHpping  of  the  hga- 
ture  from  the  cut  end  of  an  artery  was  at  that  time  regarded  as  very  great,  and 
to  prevent  it  the  needle  was  placed  on  the  ligature  after  it  was  tied,  and  the 
thread  was  passed  through  the  artery  close  to  the  ligature  and  tied  with  the  knot 
already  made. 

One  year  later,  January  4th,  1814,  Post  applied  a  ligature  to  the  external 
iliac  for  inguinal  aneurism.  It  was  the  second  operation  on  the  artery  in  this 
country,  Dorsey,  of  Philadelphia,  having  operated  in  1811  successfully.  The 
important  feature  in  Post's  case  was  the  necessity  of  opening  the  peritoneal 
cavity  to  reach  the  artery,  and  the  recovery  of  the  patient.  It  is  stated  in  the 
report  that  the  strength  and  thiclmess  of  the  peritoneum  were  considerably 
greater  than  natural,  and  its  adhesion  to  the  ligament  so  firm  that  the 
separation,  which  is  ordinarily  so  easily  effected.  Was  found  in  this  case  alto- 
gether impracticable.  To  arrive  at  the  artery,  therefore,  under  these  cir- 
cumstances, it  was  necessary  to  cut  through  the  peritonemu,  and  thus  "  expose 
the  patient  to  the  additional  hazard  of  inflammation  of  this  membrane,  to 
which  it  is  generally  supposed  to  be  very  liable  when  an  opening  is  made  into 
the  common  cavity  of  the  abdomen."  But  to  accomplish  this  object  there 
was  no  alternative,  nor  did  Post  hesitate  in  proceedmg  with  the  operation  in 
this  manner. 

On  the  28th  of  November,  1816,  Post  again  ligated  the  common  carotid  ar- 
tery for  a  pulsating  tumor  of  the  neck.  The  patient  recovered  from  the  opera- 
tion, but  died  two  years  later,  and  the  autopsy  disclosed  a  tumor  with  no  indi- 
cations of  a  previous  aneurism.  It  was  to  this  case  that  Mott  often  alluded  in  his 
lectures,  illustrating  the  difficulties  of  correctly  diagnosing  an  aneurism  from  an 
abscess  or  solid  tumor  overlying  an  artery.  At  the  consultation  Post  diagnosed 
the  tumor  as  an  aneurism,  Stevens  as  an  abscess,  and  Mott  as  a  solid  tumor; 
Stevens  suggested  to  Post  the  propriety  of  exploring  it  by  puncture,  whereupon 
Post  responded  by  handing  Stevens  a  lancet.  Stevens  declined  by  passing  the 
lancet  to  Mott,  who  refused  to  receive  it,  and  Post  was  allowed  to  exercise  his 
discretion. 

Post's  last  and  most  notable  pioneer  work  was  the  ligation  of  the  left  sub- 
clavian, in  its  third  part,  for  aneurism  of  the  brachial  artery.  This  was  the 
eighth  recorded  ligation  of  the  subclavian  artery,  the  third  which  recovered,  and 
the  first  in  this  country  by  the  new  method.  The  most  interesting  feature  of  the 
case  was  the  rupture  of  the  aneurism  and  the  discharge  of  its  contents  during 
convalescence,  with  the  final  complete  recovery  of  the  patient. 

From  this  review  it  appears  that  Dr.  Post,  previous  to  the  year  1816,  had 
applied  the  ligature  successfully  to  five  different  arteries,  twice  to  the  carotid. 
His  success  has  not  been  excelled,  if  we  consider  the  complications  he  encorm- 
tered,  in  any  period  anterior  to  antisepsis.    The  secret  of  his  success,  aside  from 


42  AMERICAN  PRACTICE  OF  SURGERY. 

his  great  skill  as  an  operator,  is  found  in  the  extreme  cleanliness,  not  only  of  his 
person,  but  of  his  instruments  and  the  womid  and  dressings,  thus  securing  asep- 
sis. In  the  case  of  opening  the  peritoneum,  he  followed  the  operation  with  "an 
active  cathartic,  composed  of  an  infusion  of  senna,  manna,  and  cream  of  tartar, 
which  caused  frequent  and  copious  discharges" — a  form  of  treatment  w^hich 
some  distinguished  operators  have  latterly  adopted  as  a  preventive  of  peritonitis. 

Brilliant  as  had  been  the  career  of  Post  m  his  pioneer  work  of  introducing 
the  new  method  of  treatmg  aneurism  into  American  practice,  Mott,  his  pupil, 
was  destined  to  excel  him  in  the  number,  variety,  and  severity  of  operations, 
and  in  the  perfection  and  precision  of  details.  He  had  a  genius  for  scientific 
operative  surgery.  Nothing  was  done  haphazard.  Every  detail,  however  mi- 
nute and  apparently  unimportant,  was  carefully  studied,  and  provision  was 
made  to  meet  every  possible  accident.  He  was  by  habit  and  training  an  aseptic 
surgeon.  His  personal  neatness  attracted  public  attention.  His  instruments 
were  carefully  cleaned  before  as  well  as  after  each  operation,  and  every  one  as- 
sisting was  required  to  be  clean  and  to  protect  the  wound  and  parts  around  it 
from  every  possible  source  of  contamination.  One  of  his  pupils  illustrated  his 
habitual  cleanliness  as  follows :  Being  present  when  another  surgeon  opened  an 
abscess,  Mott  rolled  up  his  coat  sleeves,  put  his  hands  behind  him  during  the 
operation,  and,  when  the  pus  began  to  flow,  proceeded  to  wash  his  hands  as  if 
he  had  been  the  operator. 

Mott's  trainmg  was  well  adapted  to  prepare  him  to  take  up  the  work  which 
his  preceptor  was  about  to  lay  down.  In  addition  to  his  pupilage  under  Post, 
he  visited  London  and  became  an  assistant  of  Mr.  Astley  Cooper.  Cooper  was 
the  first  to  apply  a  ligature  to  the  carotid  artery  for  aneurism — 1805 — but  un-  ■ 
successfully.  In  1808  he  repeated  the  operation,  successfully,  and  Mott  was 
present  as  his  assistant  and  always  spoke  enthusiastically  of  this  opportunity  to 
witness  what  was  considered  pioneer  work  in  operative  surgery.  A  few  montlis 
later,  Cooper  attempted  to  ligate  the  left  subclavian  between  the  scaleni  muscles, 
but  failed.  Mott  took  part  in  this  operation  also,  and  was  deeply  impressed 
with  the  difficulties  of  the  procedure  and  Cooper's  skill  and  candor.  He  says: 
"  After  working  indefatigably  with  all  his  emment  skill  and  superlative  tact  for 
an  hour  and  a  half,  he  abandoned  the  operation." 

Mott's  pioneer  work  began  with  the  ligature  of  the  arteria  innominata.  This 
was  not  only  his  greatest  achievement  in  operative  surgery,  but  it  was  the  most 
brilliant  operation  ever  imdertaken  by  any  surgeon  in  the  history  of  operative 
surgery  to  that  date.  Nor  has  it  ever  been  excelled  in  this  department  of  sur- 
gery, if  we  give  due  weight  to  all  of  the  circumstances  attending  the  operation. 
It  was  by  no  means  suddenly  conceived  and  executed  as  an  emergency  opera- 
tion, but  was  the  ripe  fruit  of  years  of  study  and  preparation.  He  states  that 
"since  the  publication  of  Allan  Burn's  invaluable  work  on  the  surgical  anatomy 
of  the  he-ad  and  neck,  I  have  laeen  in  the  habit  of  showing,  in  mv  surgical  lect- 


INTRODUCTION.  43 

ures,  the  practicability  of  securing,  in  a  ligatui'e,  the  arteria  innominata;  and  I 
have  had  no  hesitation  in  remarking  that  it  was  my  opinion  that  this  artery 
might  be  taken  up  for  some  condition  of  aneurisms,  and  that  a  surgeon  with  a 
steady  hand  and  a  correct  knowledge  of  the  parts  would  be  justified  in  doing  it." 
The  proper  case  presented  itself  March  1st,  1818,  and  he  says :  "  I  could  not  for  a 
moment  hesitate  in  recommending  and  performing  the  operation."  Dr.  Wright 
Post,  whom  he  had  so  often  aided,  now  became  his  adviser  and  assistant. 

Though  the  operation  failed  after  giving  the  most  encouraging  prospect  of 
■success,  Mott  was  not  disheartened,  but  regarded  its  practicability  and  propriety 
as  satisfactorily  established  by  this  case,  and  predicted  that  it  would  prove  to  be 
"the  bearer  of  a  message  to  surgery,  containing  new  and  important  results." 

The  arteria  innominata  was  repeatedly  ligatured  subsequently,  but  it  was  re- 
served for  an  American  surgeon  to  secure  the  first  successful  result.  The  oper- 
ator was  Dr.  A.  W.  Smyth,  of  New  Orleans.  The  operation  was  performed  in 
1864.  In  this  case  the  carotid  was  ligated  at  the  same  time,  and  on  the  fifty- 
fourth  day  the  vertebral  was  also  ligated. 

Scarcely  less  memorable  than  Mott's  operation  on  the  arteria  innominata,  and 
creditable  as  a  great  surgical  achievement,  was  Dr.  J.  Kearney  Rodgers'  liga- 
tion of  the  left  subclavian,  within  the  scaleni  muscles.  The  operation  was  per- 
formed on  the  14th  day  of  October,  1845.  It  is  an  interesting  fact  that  Mott 
was  one  of  the  consultants  and  opposed  the  operation,  though  he  admitted  that 
it  might  possibly  "  be  tied  by  a  careful  and  well-informed  surgeon,"  yet  he  "  con- 
sidered that  it  was  improper  to  do  so."  Colles,  of  Dublin,  who  was  the  first  to 
ligate  the  right  subclavian  in  its  first  part,  condemned  a  similar  operation  on  the 
left,  stating  that  there  was  "  such  a  combination  of  difficulties  as  must  deter  the 
most  enterprising  surgeon  from  undertaking  this  operation  on  the  left  side." 
Of  the  consultants,  Drs.  Mott  and  Stevens,  though  opposed  to  the  operation, 
had  such  confidence  in  Dr.  Rodgers's  ability  that  they  left  the  question  of  an  op- 
eration to  his  discretion. 

In  his  report  of  the  case  Dr.  Rodgers  says:  "Although  a  decided  majority 
of  the  consultation  agreed  as  to  the  propriety  of  the  operation  of  securing  the 
artery  for  aneurism,  still,  as  my  colleagues  kindly  left  it  with  me  to  decide 
whether  it  should  be  midertaken,  I  felt  it  incumbent  on  me  to  investigate  the 
subject  with  great  care,  and  accordingly  gave  it  my  most  sedulous  attention.  I 
was  the  more  anxious  because,  in  the  only  case  in  which  the  attempt  had  been 
made  by  Sir  Astley  Cooper,  in  1809,  that  eminent  surgeon  failed  in  securing  the 
vessel.  ...  I  had  always  considered  it  as  a  perfectly  justifiable  operation,  and 
one  that  a  careful  surgeon  conversant  with  anatomy  could  accomplish  if  the 
tumor  were  of  moderate  size." 

Rodgers  did  not  hesitate  to  a.ssume  the  responsibility  which  the  action  of 
his  colleagues  imposed  upon  him,  and,  true  to  his  convictions  of  duty,  proceeded 
to  execute  the  trust  committed  to  his  care.    The  operation  proved  to  be,  in  every 


44  AMERICAN  PRACTICE  OF  SURGERY. 

respect,  as  difficult  as  had  been  alleged,  but  he  was  fully  prepared  for  every 
emergency.  The  ligature  was  successfully  applied,  and  for  several  days  every- 
thing promised  success;  but  on  the  thirteenth  day  a  hemorrhage  occirrred, 
which  was  repeated,  and  the  patient  died  on  the  fifteenth  day.  The  lesson 
which  Rodgers  drew  from  the  operation  was  that  the  vertebral  artery  and,  if 
possible,  the  thyroid  axis  should  be  secured  at  the  same  time  by  ligature.  In 
concluding  his  report  he  says  that,  though  the  operation  was  misuccessful  in 
curing  the  aneurism,  he  trusts,  "from  the  knowledge  thence  derived,  we. shall 
be  enabled  to  enlarge  our  sphere  of  usefulness,  and  be  the  means  of  preservmg 
human  life." 

John  Kearney  Rodgers  (1793-1851)  was  born  in  this  city  in  1793.  He  was  the 
son  of  Dr.  J.  R.  B.  Rodgers,  an  eminent  phj^sician  of  this  city  during  the  latter  part 
of  the  last  century.  He  was  a  graduate  of  Princeton  College,  New  Jersey.  He 
studied  medicine  under  Prof.  Wright  Post,  of  the  College  of  Physicians  and  Surgeons, 
and  graduated  in  1816.  He  then  visited  Europe  and  attended  the  lectm-es  of  Sir 
Astley  Cooper,  Brodie,  Travers,  and  Abernethy.  On  his  return  he  was  appointed 
surgeon  to  the  New  York  Hospital,  on  the  resident  staff  of  which  he  had  served.  He 
died  of  portal  phlebitis,  on  the  9th  of  November,  1851,  aged  fifty-eight  years. 

ilott  was  the  first  surgeon  wdio  ligated  the  primitive  iliac  for  aneurism.  The 
operation  was  performed  on  the  15th  day  of  March,  1827,  and  was  executed 
with  his  usual  care  and  attention  to  all  of  the  details.  The  size  of  the  tumor  and 
the  adhesions  of  the  peritoneum  rendered  the  procedure  very  difficult,  but  the 
operator  was  rewarded  with  the  recovery  of  his  patient,  who  was  living  thirty 
years  after.  In  the  practice  of  other  surgeons  the  operation  has  proved  very 
fatal.  During  the  first  twenty-five  years  after  Mott's  operation,  the  common 
iliac  was  ligated  eighteen  times  with  fourteen  deaths — a  mortality  of  upward  of 
seventy-seven  per  cent. 

The  experience  of  Mott  in  the  ligation  of  arteries  was  very  great  and  his  suc- 
cess far  exceeded  that  of  any  contemporary  surgeon.  According  to  his  own  state- 
ment, he  ligated  the  arteria  innominata  once,  unsuccessfully;  the  common  iliac 
once,  successfully ;  the  subclavian  artery  m  its  third  part  six  times,  all  the  cases 
were  successful;  the  common  carotid  thu'ty-two  times,  with  but  five  failures;  the 
external  iliac  six  times,  with  two  failures  (one  patient  died  of  drunkenness) ;  the 
femoral  fifty- three  times,  the  failures  being  unknown.  He  had  but  one  case  of 
mortific;  ition  of  the  extremity  after  ligature  of  an  artery.  This  success  Black- 
man  attributed  to  Mott's  great  attention  to  the  most  minute  details,  both  dur- 
ing the  operation  and  duruig  the  subsequent  treatment  of  his  patients. 

In  1812,  Gibson,  of  Philadelphia,  placed  a  ligature  on  a  bleeding  vessel  in  a 
gunshot  wound  of  the  grom,  and  after  the  death  of  the  patient  it  was  foimd  that 
the  injured  vessel  was  the  common  iliac.  The  operation  had  no  scientific  value, 
and  should  not  be  classified  with  operations  deliberately  planned  and  executed. 

The  ligation  of  the  external  iliac  was  first  performed  in  this  cotmtry,  as  already 


INTRODUCTION.  45 

noted,  by  John  Syng  Dorsey.  This  was  a  most  creditable  performance,  and 
antedated  Post's  operation  three  years.  Dorsey  operated  August  19th,  1811. 
The  special  feature  of  his  case  was  the  use  of  an  aneurismal  needle,  consisting  of 
a  blunt  bodkin  of  silver,  properly  bent,  and  held  in  a  curved  forceps,  the  handles 
of  which  were  firmly  tied  together.  The  curved  forceps  used  on  this  occasion  to 
pass  the  aneurismal  needle  was  the  invention  of  Physick,  and  was  also  used  by 
Post  in  his  operations.  It  is  interesting  to  notice  that  a  thermometer  was  em- 
ployed to  test  the  temperature  of  the  limb,  and  it  was  foimd  to  become  five  de- 
grees colder  than  the  other. 

Gratifying  as  was  the  success  of  American  surgeons  in  their  pioneer  work  in 
the  ligature  of  arteries,  and  accurate  as  was  the  technique  of  the  operation  which 
they  had  devised,  there  was  still  a  fatal  defect  which  was  to  be  remedied,  viz., 
hemorrhage  on  the  separation  of  the  ligature.  The  practice  of  applying  a  silk 
ligature  so  tightly  as  to  divide  the  inner  coat  of  the  artery,  for  the  purpose  of 
securing  the  union  of  the  ruptured  surfaces,  was  the  rule  with  surgeons.  The 
result  was  the  gradual  division  of  the  artery  by  a  process  of  ulceration  due  to 
the  irritation  of  the  imabsorbable  ligature,  and  if  union  had  not  taken  place,  as 
too  often  happened,  hemorrhage  was  the  result.  Physick,  trained  in  the  school 
of  Hunter,  suggested  the  remedy  for  this  evil,  viz.,  the  use  of  "dissoluble"  liga- 
tures, the  pressure  of  the  internal  surfaces  of  the  artery  together  without  injur- 
ing its  coats,  and  healing  the  wound  by  first  intention.  At  his  suggestion,  and 
under  his  directions,  a  series  of  experiments  were  performed  with  animal  mate- 
rial, and  French  kid,  which  was  absorbed  after  several  days  without  injury  to 
the  artery,  was  selected,  as  described  by  Dorsey. 

A  very  important  contribution  to  the  subject  of  animal  ligatures  was  made 
in  1827  by  Dr.  Horatio  Gates  Jameson,  of  Baltimore,  Md.,  in  a  prize  essay,  en- 
titled, "  Observations  upon  Traumatic  Hemorrhage,  Illustrated  by  Experiments 
upon  Living  Animals." 

Horatio  Gates  Jameson  (1778-1855)  was  born  at  York,  Pa.,  in  1778,  and  gradu- 
ated in  medicine  from  the  University  of  Maryland  in  1813.  He  located  in  Baltimore, 
Md.,  and  attained  a  high  rank  as  a  surgeon.  He  was  the  founder  of  Washington 
Medical  College  and  professor  of  surgery,  1827-35.    He  died  August  24th,  1855. 

Jameson's  conclusions  were  as  follows : 

1.  If  an  artery  is  sufficiently  healthy  to  admit  of  its  obliteration  by  adhesion 
of  its  sides,  it  is  best  done  by  a  ligature  which  will  neither  cut  its  coats  nor 
strangulate,  except  in  parts,  the  true  vasa  vasorinn,  so  that  the  continuity  of 
the  vessel  shall  not  be  destroyed,  although  we  obliterate  its  calibre. 

2.  If  an  animal  ligature  of  the  proper  kind  be  properly  applied,  the  vessel 
will  be  obliterated,  the  wound  may  be  healed  by  the  first  intention,  and  the  liga- 
ture will  not  cause  suppurative  inflammation,  but  in  due  time,  being  dissoluble, 
the  whole  will  be  removed  by  the  absorbents;   there  will  be  no  breach  of  con- 


46  a:\iericax  practice  of  surgery, 

tinuity  in  .the  artery.  .  .  .  The  vessel,  which  durmg  the  state  of  inflammation 
and  effusion  of  Ijmiph  was  converted  into  a  cord,  will  pretty  soon  afterward  be 
resolved  into  a  flat  string  of  white  cellular  structure. 

The  experiments  of  Dorsej'  and  Jameson  brought  the  operation  of  ligating 
arteries  to  scientific  perfection  by  preventing  secondary  hemorrhage  and  secur- 
ing healing  of  the  womid  by  first  intention. 

An  important  feature  of  Jameson's  experiments,  to  which  he  seems  to  have 
attached  little  importance,  was  the  discovery  that,  as  the  animal  ligatm'e  under- 
went absorption,  it  became  "  completely  enveloped  in  a  strong  membranous 
capsule.  .  .  .  This  arrangement  of  the  capsule  seemed  to  have  the  effect  of 
drawing  the  button-like  knobs  (ends  of  the  ligature,  in  the  state  of  yellow  pulp) 
together,  and  was  thus  closing  the  vessel.  .  .  .  The  capsule  covering  the  knobs 
or  ends  of  the  string  was  fully  equal  in  strength  to  the  outer  coat  of  the  artery, 
and  therefore  there  was  no  tendency  to  hemorrhage."  In  the  demonstration 
of  this  encircling  ring  or  capsule  ^hich  forms  when  animal  ligature  is  employed 
for  ligature,  Jameson  anticipated  Lister,  who  describes  it  in  his  experiment  as  a^ 
ring  of  new  tissue  enveloping  the  dissolving  animal  ligatm'e.  He  regarded  it  as 
of  great  importance  in  the  prevention  of  hemorrhage.  It  certainly  strengthens 
the  artery  at  the  point  of  ligature,  where  the  artery  has  been  rendered  very 
weak  by  the  strangulation  of  nutrient  vessels.  It  is  in  effect  like  the  provisional 
callus  which  forms  at  the  seat  of  fracture  of  a  bone — a  temporary  means  of  pro- 
tecting a  weak  point  in  the  vessel  mitil  repair  takes  place. 

Jameson  not  only  demonstrated  at  that  early  period  the  true  method  of 
procedure  to  secure  success  in  the  ligature  of  arteries  by  experiments  on  ani- 
mals, but  by  a  large  series  of  operations  in  practice,  as  in  ligating  the  carotid, 
the  iliac,  the  femoral,  the  radial,  and  other  arteries.  But  the  real  value  of  his 
teaching,  though  sustained  by  the  authority  of  Physick,  was  not  appreciated  by 
contemporary  surgeons.  It  was  not  until  the  introduction  of  antiseptics  had 
awakened  a  new  interest  in  measures  for  the  prevention  of  suppuration  of 
wounds  that  the  practice  of  Jameson  received  the  attention  which  it  merited. 
Meantime  his  demonstrations  had  been  forgotten,  and  the  new  method  became 
popular  as  one  of  the  features  of  antiseptic  surgery.  Essentially,  however,  the 
practice  of  to-day  is  along  the  lines  laid  down  by  Jameson.  The  employment 
of  metallic  ligatures,  as  silver  wire,  by  Dr.  Warren  Stone,  of  New  Orleans,  and 
lead  and  other  metals,  has  not  proved  as  useful  as  animal  material,  owing  to  its 
liability  to  find  its  way  out  in  time,  with  suppuration. 

Amputation  of  limbs,  which  had  been  the  subject  of  contention  dm'ing  the 
latter  half  of  the  seventeenth  and  the  whole  of  the  eighteenth  centuries,  was  at 
its  culmination  on  the  opening  of  the  nineteenth  century.  The  questions  at 
issue  were:  (1)  Shall  the  method  be  the  circular  or  flap,  with  their  many  modi- 
fications? and  (2)  shall  the  healmg  be  by  first  intention  or  by  granulation?    In 


INTRODUCTION.  47 

1816  there  appeared  in  Baltimore  "A  Tract  on  Amputation,"  by  Prof.  John  B. 
Davidge,  of  the  University  of  Maryland,  the  object  of  which  was  to  introduce 
the  "American  method"  of  amputation.  The  "tract"  is  a  very  complete  trea- 
tise on  amputation,  being  a  careful  and  critical  review  of  the  methods  of  proced- 
ure since  the  time  of  Celsus.  The  author  states  that  he  had  been  investigating 
the  opinions  and  works  of  the  surgical  writers  of  France  and  Britain  for  ten  or 
fifteen  years,  anxious  to  bring  amputation  to  some  degree  of  perfection.  The 
"American  method"  is  as  follows:  Two  lateral  semi-elliptical  flaps  are  made,  one 
on  either  side  of  the  limb,  consisting  only  of  the  skin  and  cellular  tissue.  These 
are  dissected  from  the  muscles  and  of  a  size  sufficient  to  cover,  freely  and  easily, 
the  whole  stump  when  laid  together;  that  is,  each  flap  must  be  at  least  the  semi- 
diameter  of  the  limb  and  so  full  as  not  to  be  in  any  way  upon  the  stretch  when 
laid  down.  The  flaps  being  thus  dissected  from  the  muscles  and  reflected  back, 
a  circular  cut  is  to  be  made  with  a  large  knife  perpendicularly  down  to  the  bone, 
and  completely  around  it ;  the  muscles  are  now  separated  from  the  bone  an  inch 
or  more  farther  up,  and  then,  with  the  muscles  well  retracted,  the  saw  is  applied 
as  closely  as  possible  to  the  edge  of  the  muscles,  and  the  bone  sawed  off.  The 
vessels  being  all  well  secured,  the  flaps  are  well  coaptated  and  adjusted  to  the 
face  of  the  stump,  and  maintained  in  position  by  adhesive  straps,  the  ligatures 
being  brought  out  of  the  lower  angle  of  the  wound. 

The  advantages  claimed  for  this  method  are:  1.  Complete  drainage,  thus 
preventing  suppuration  from  retained  fluids,  as  occurs  when  the  wound  is  trans- 
verse. 2.  The  freshly  cut  surfaces  are  accurately  applied  to  each  other,  which 
favors  union  by  first  intention,  and  no  foreign  body,  except  the  ligatures,  will 
"  provoke  inflammation  or  disquiet  the  economy  of  the  parts."  3.  The  stump  is 
more  serviceable  for  future  use  than  those  left  after  other  methods. 

"The  American  method"  was  approved  by  many  surgeons  and  was  fre- 
quently performed  with  marked  success,  but  it  did  not  receive  the  attention 
which  its  merits  deserved.  Several  years  since,  the  writer  made  a  careful  study 
of  the  results  of  the  different  methods  of  amputation  in  our  hospitals,  and,  com- 
ing to  the  same  conclusion  as  Professor  Davidge,  drew  similar  figures  of  the  line 
of  incisions  and  the  resulting  stump,  though  unaware  of  the  existence  of  this 
"Tract  on  Amputation." 

John  Beale  Davidge  (1768-1829)  was  born  at  Annapolis,  Md.,  1768.  He  attended 
medical  lectures  at  Philadelphia  and  Edinburgh,  but  received  his  degree  at  Glasgow, 
1793.  He  located  at  Baltimore,  1796.  In  1807  he  founded  the  Medical  Department 
of  the  University  of  Maryland,  and  was  the  professor  of  anatomy  and  surgery,  1807- 
29.  He  took  a  prominent  position  as  a  surgeon,  had  a  "pleasing  address,  very 
remarkable  colloquial  powers,  and  high  professional  character."     He  died  in  1829. 

The  reduction  of  dislocations  was  a  subject  of  great  interest  to  British  sur- 
geons.   According  to  Mr.  Pott,  the   leading  authority  in  British  surgery  during 


48  AAIERIC-1^'  PRACTICE  OF  SURGERY. 

the  latter  half  of  the  eighteenth  century,  dislocations  were  reduced  by  force.  Of 
the  machines  for  that  purpose,  he  saj^:  "Many  or  most  of  them  are  much  more 
calculated  to  pull  a  man's  joints  asunder  than  to  set  them  to  rights."  With  true 
scientific  intuition  he  declares  that  "  replacing  a  dislocation  would  require  very 
httle  trouble  or  force,  were  it  not  for  the  resistance  of  the  muscles  and  tendons 
attached  to  and  connected  with  them."  Little  if  any  useful  progress  was  made 
in  the  direction  pointed  out  by  Pott,  to  determine  the  principles  governing  the 
reduction  of  dislocations,  imtil  the  attention  of  American  surgeons  was  directed 
to  the  subject.  Now,  the  most  formidable  of  these  dislocations,  those  of  the 
femur  at  the  hip-joint,  are  reduced  in  American  practice  without  violence  or  pain, 
by  simple  manipulation  of  the  limb  with  the  hands.  The  several  steps  in  the 
process  of  investigation,  by  which  the  principles  governing  the  natural  and  ra- 
tional method  of  reducing  all  dislocations  was  discovered,  illustrate  the  scientific 
spirit  of  American  practitioners  as  well  as  teachers  of  surgery: — 

Occasional  reductions  of  dislocations  at  the  hip-joint  during  manipulations 
of  the  limb,  even  after  protracted  efforts  had  been  made  at  reduction  with  power- 
ful machines,  have  been  recorded  from  the  time  of  Hippocrates.  But  they  were 
regarded  as  accidents,  having  no  scientific  value.  Physick  reduced  a  dislocation 
of  the  femur  by  manipulation  in  1S12.  after  the  pulleys  had  failed.  He  believed 
that  the  cause  of  previotis  failm'e  was  due  to  the  escape  of  the  head  of  the  bone 
through  a  rent  in  the  capsule,  and  that  the  head  had  become  fixed  as  in  a  button- 
hole, from  which  he  dislodged  it. 

In  lS-31  Dr.  Nathan  R.  Smith,  of  Baltimore,  Md.,  pubUshed  "Eemarls  on 
Dislocations  of  Uie  Hip-joint,"  and  states  that  the  principles  which  he  endeavors 
to  establish,  relative  to  reduction,  were  derived  in  part  from  the  lectures  of  his 
father,  Dr.  Nathan  Smith,  professor  of  surgery  in  Yale  College.  It  appeal's  from 
the  record  that  as  earh-  as  ISll  his  father  explained  a  method  of  reducing  the 
dislocations  of  the  femur  at  the  hii>joint  by  manipulations  of  the  limb  with  the 
hands,  without  the  aid  of  mechanical  appliances.  His  method  of  procedure  was 
based  on  a  careful  study  of  the  action  of  the  muscles  attached  to  the  upper  ex- 
tremity of  the  femur.  The  author  thus  states  his  conclusions :  "  There  is,  no 
doubt,  a  constant  mechanical  principle  upon  which  the  i-eduction  is  effected  ia 
such  cases,  and  one  which  would  perhaps  succeed  in  nearly  aU  cases  if  we  knew 
how  to  employ  it  tindei^tandingly  and  with  precision,  and  did  not  avail  our- 
selves of  it  by  mere  haphazard.  If  a  gentle  movement  of  a  pecuhar  kind  succeed 
in  one  case  of  complete  dislocation  on  the  dorsum  ilii  after  all  other  means  have 
failed,  ought  not  this  movement,  if  well  understood,  to  succeed  in  other  cases 
better  than  the  usual  mode?  The  mechanism  of  these  dislocations  is  certainly 
the  same  in  all  of  this  variety,  .  .  .  furnishing  the  same  impediments  and  the 
same  aids  in  every  case.  This  frequent  failure  of  art  and  the  success  of  accident 
satisfy  me  that  there  is  some  important  principle  relative  to  the  mechanism  of 
these  dislocations  which  is  not  understood.      Accident  ought  not  to  accompUsh 


INTRODUCTION.  49 

the  reduction  of  a  bone  with  more  ease  than  art.  When  it  does  so,  such  accident 
should  be  our  instructor,  and  teach  us  the  mechanism  by  which  it  operated,  and 
this  we  should  repeat  in  similar  cases." 

The  author  then  proceeds  to  discuss  the  mode  of  applying  force  in  the  reduc- 
tion of  dislocations  of  the  hip,  and,  in  illustration  of  the  adaptation  of  manipula- 
tion to  meet  the  varying  action  of  the  muscles  affected  by  the  dislocation  as  com- 
pared with  the  pulleys,  he  mentions  the  case  of  reduction  by  Physick  and  adds 
a  case  narrated  by  his  father,  "in  which  he  promptly  succeeded  by  the  mere 
force  of  hands  in  effecting  reduction."  The  description  of  the  muscles  concerned 
in  reduction  is  given  in  detail  and  the  method  of  manipulating  the  limb  is  illus- 
trated with  engravings.  "The  free  flexion  of  the  thigh  upon  the  pelvis"  was  re- 
garded "as  a  very  important  part  of  the  compound -movement."  For  twenty 
years  no  further  attention  seems  to  have  been  given  to  the  subject,  and  it  is 
doubtful  whether  the  views  of  Nathan  Smith  had  become  known  to  the  profes- 
sion at  large. 

In  1851  Dr.  William  W.  Reid,  of  Rochester,  N.  Y.,  published  a  paper  on 
"Dislocation  of  the  Femur  on  the  Dorsum  Ilii.  Reduction  without  Pulleys  or 
Any  Other  Mechanical  Power."  He  states  that  he  had  been  present  at  several 
operations  for  the  reduction  of  dislocations  at  the  hip-joint  by  means  of  pulleys, 
and  was  impressed  with  the  apparently  unnecessary  force  employed.  For  ten 
years  he  studied  the  mechanism  of  these  dislocations,  and  came  to  the  conclu- 
sion that  "  the  difficulty  lay  in  the  extension  of  the  .  .  .  adductors  and  rotators, 
and  that  all  traction  ...  on  the  dislocated  bone  only  increased  this  tension, 
and  could  do  nothing  toward  bringing  it  into  place,  except  at  the  hazard  of  al- 
most certain  rupture  of  some  of  these  muscles  or  of  fracture  of  the  neck." 

Guided  by  this  conclusion  and  the  experience  gained  by  his  experiments, 
Reid  practised  manipulations  and  evolutions  on  the  skeleton  imtil  he  had  deter- 
mined  that  "  dislocation  of  the  femur  on  the  dorsum  ilii  ...  is  reduced  with  the 
greatest  ease  in  a  few  seconds  or  minutes,  without  much  pain,  without  an  assist- 
ant, without  pulleys  ...  or  any  other  mechanical  means,  simply  by  flexing 
the  leg  on  the  thigh,  carrying  the  thigh  over  the  sound  one  upward  over  the  pel- 
vis, as  high  as  the  umbilicus,  and  then  by  abducting  and  rotating  it." 

Reid  gave  wide  publicity  to  his  paper  and  discussed  his  method  before  medical 
societies.  Surgeons  in  hospital  practice  who  tested  its  merits  found  that  it  was 
a  vast  improvement  upon  the  pulley  and  other  appliances. 

In  1853  Dr.  Moses  Gunn,  professor  of  surgery  in  Rush  Medical  College,  Chi- 
cago, who  had  taught  Reid's  method,  published  an  account  of  experiments  made 
in  1851-52  to  determine  the  obstacles  to  reduction  of  hip-joint  dislocations. 
His  conclusion  was  that  the  "  untorn  portion  of  the  capsular  ligament,  by  bind- 
ing down  the  head  of  the  dislocated  bone,  prevents  its  ready  return  over  the 
edge  of  the  cavity  to  its  place  in  the  socket."  He  rejected  the  opinion  of  Reid 
that  the  opposing  forces  are  the  muscles.    The  untorn  portion  of  the  capsular 


50  a:\iericax  practice  of  surgery. 

ligament  to  which  he  refers  is  "  the  anterior  and  inferior  half  of  the  capsule  "  (which 
includes  the  ilio-femoral  or  Y-ligament  of  Bigelow),  and  this,  he  states,  is 
"  the  sole  agent  which  gives  character  to  those  dislocations,  and,  with  the  excep- 
tion of  the  fascia  lata,  the  only  obstacle  to  he  overcome  by  our  efforts  to  reduce 
them." 

In  1861  Dr.  Henry  J.  Bigelow,  professor  of  surgery  m  the  Harvard  Medical 
College,  who  also  had  taught  Reid's  method,  was  led  to  expose  a  jomt,  the  luxa- 
tion of  which  had  been  the  subject  of  a  lecture,  and  was  surprised  to  observe  the 
simple  action  of  the  ligament  (the  anterior  and  inferior  half  of  the  capsule,  al- 
luded to  by  Gunn).  The  dislocated  joint  was  in  the  following  condition:  1. 
Great  laceration  of  the  muscles  about  the  joint.  2.  The  ligamentum  teres 
broken.  3.  Laceration  of  the  inner,  outer,  and  lower  parts  of  the  capsule.  4. 
The  anterior  and  upper  parts  of  the  capsule  uninjm'ed,  and  presenting  a  strong 
fibrous  band,  fan-shaped,  and  slightly  forked.  On  dividing  the  remaining 
tendinous  and  muscular  fibres  about  the  joint,  excepting  this  fibrous  band,  it 
was  found  that  the  four  commonly  described  dislocations  of  the  hip  could  still 
be  exliibited  without  difficulty,  and  that  in  each  of  them  the  anterior  portion  of 
the  capsular  ligament,  which  alone  remained,  sufficed  at  once  to  direct  the  limb 
to  its  appropriate  position  and  to  fix  it  there.  On  the  other  hand,  if  the  entire 
capsule  of  the  hip-joint  be  divided  and  the  muscles  left  intact,  these  dislocations 
are  but  imperfectly  represented. 

The  conclusion  of  Professor  Bigelow,  as  a  result  of  his  investigations,  was  that 
the  muscles  play  but  a  subordinate  and  occasional  part,  either  in  hindering  re- 
duction or  in  determining  the  character  of  the  deformity,  but  that  these  condi- 
tions are  chiefly  due  to  the  resistance  of  the  ligament.  The  practical  result  of 
this  conclusion  is  thus  stated  by  Bigelow:  "The  theory  here  advanced  recog- 
nizes the  anterior  portion  of  the  capsular  ligament  as  the  exponent  of  the  total 
agency  of  the  capsule  in  giving  position  to  the  dislocated  limb,  and,  what  is  more 
important,  is  so  identified  with  the  phenomena  of  luxation  that  reduction  must 
be  accomplished  almost  wholly  with  reference  to  it." 

This  discovery  led  Bigelow  to  review  the  whole  subject  of  dislocations  at  the 
hip-joint  and  determine  the  peculiarities  of  each  and  the  special  methods  of  re- 
duction applicable  to  the  different  forms.  The  course  of  study  which  he  pursued 
in  demonstrating  the  Y-ligament  and  its  relations  to  the  position  of  the  head  of 
the  femur  in  the  several  dislocations,  and  the  exact  direction  in  which  the  forces 
emplo}-ed  in  reduction  should  be  applied,  forms  one  of  the  brightest  chapters  in 
scientific  surgery. 

Thus,  after  a  generation  of  investigation  by  American  surgeons,  the  "con- 
stant mechanical  principle  upon  which  the  reduction  is  effected"  in  hip-joint 
dislocations,  suggested  bj'  Nathan  R.  Smith,  was  discovered,  and  the  method  of 
Reid,  by  which  a  dislocation  on  the  dorsum  ilii  "  is  reduced  with  the  greatest  ease 
in  a  few  seconds  or  minutes,  without  much  pain,  without  an  assistant,  without 


INTRODUCTION.  51 

pulleys,"  was  made  applicable  to  all  dislocations  at  the  hip-joint.  Though  Bige- 
low  gives  the  paternity  of  the  new  method,  which  is  concisely  expressed  in  the 
words  "flex,  abduct,  evert,"  to  Nathan  Smith,  the  world  is  indebted  to  Reid  for 
the  practice  of  reducing  dislocations  on  the  dorsum  ilii  by  manipulation,  and  to 
Bigelow  for  an  extension  of  that  method  to  all  other  forms  of  dislocations  at  the 
hip-joint. 

The  treatment  of  fractures  was  vigorously  discussed  by  foreign  surgeons  at 
the  beginning  of  the  last  century.  Samuel  Cooper,  author  of  the  "  Surgical  Dic- 
tionary," and  historian  of  British  surgery,  referring  to  the  comparison  of  French 
and  English  surgery  by  Roux,  1814,  states  that,  with  the  exception  of  the  teach- 
higs  of  Pott,  "  it  cannot  be  said  that  we  had  made  a  single  improvement  of  con- 
sequence in  the  treatment  of  any  particular  fracture." 

We  shall  illustrate  our  subject  by  noticing  the  improvements  made  by  Ameri- 
can surgeons  in  regard  to  a  single  fracture,  viz.,  that  of  the  femur.  Fractures  of 
this  bone  were  the  theme  of  constant  discussion  by  French  and  British  surgeons 
at  the  close  of  the  eighteenth  and  the  beginning  of  the  nineteenth  centuries. 
The  controversy  had  become  somewhat  of  a  national  issue.  Pott,  on  the  part  of 
the  British  surgeons,  advised  that  the  limb,  flexed  at  the  hip  and  knee,  be  laid 
on  its  side,  supported  only  by  lateral  splints  loosely  applied,  the  body  being  in- 
clined to  that  side.  His  contention  was  that,  by  thus  relaxing  the  muscles,  the 
fragments  fall  into  position  and  require  no  other  support  than  side  splints.  De- 
sault,  on  the  part  of  the  French,  placed  the  limb  in  an  extended  position  and 
applied  an  external  splint  from  the  crest  of  the  ilium  to  a  point  below  the  foot 
and  attempted  extension  and  counter-extension  as  the  governing  principle  in 
the  treatment  of  these  fractures. 

Though  both  of  these  methods  had  merits,  in  practice  they  proved  defective. 
The  relaxation  of  the  muscles  effected  by  Pott's  method  was  very  desirable,  but 
it  was  impossible  to  maintain  the  limb  quiet  in  that  position  without  more 
restraint  from  appliances  than  the  two  splints  supplied.  The  extension  and 
counter-extension  by  means  of  a  long  side  splint  in  Desault's  method  was  very  im- 
portant, but  the  plan  of  securing  it  was  inefficient;  the  extending  and  counter- 
extending  bands,  acting  obliquely,  tended  to  draw  the  upper  fragment  and  the 
foot  outward,  while  that  at  the  foot  caused  painful  excoriations  at  the  ankle. 
The  two  principles  on  which  these  methods  of  practice  were  based  were  not, 
therefore,  effectively  applied  by  the  means  devised  by  their  respective  advocates. 

American  surgeons  took  an  active  interest  in  the  treatment  of  fractures  of 
the  femur,  and  at  an  early  period  began  to  make  improvements  upon  the  French 
and  British  methods  of  practice.  Physick,  if  we  accept  Dorsey  as  authority, 
preferred  Desault's  straight  position,  for  the  reason  that  "the  muscles  very 
speedily  accommodate  themselves  to  the  new  position  caused  by  the  action 
of  the  extending  and  counter-extending  bands  at  the  extremities  of  the  splint." 


52  A^AIERICAN  PRACTICE  OF  SURGERY. 

As  the  external  or  long  splint  extended  onlj'  from  the  crest  of  the  ilium  to  a  point 
bej'ond  the  sole  of  the  foot,  the  upper  band  around  the  thigh,  acting  obliquely 
to  the  shaft  of  the  femur,  tended  to  cbaw  the  upper  fragment  outward  and  thus 
prevent  coaptation  of  the  fractured  surfaces;  while  the  lower  band,  acting  in  a 
similar  manner,  turned  the  foot  outward  and  displaced  the  lower  fragment.  To 
remedy  this  defect  Phj'sick  extended  the  splint  upward  to  the  axilla  and  placed 
a  crutch-like  form  on  the  end  to  prevent  rubbing  against  the  patient's  side.  The 
perineal  extending  band,  fastened  to  the  upper  end  of  the  splint,  now  made  trac- 
tion nearl}'  in  line  with  the  shaft  of  the  femur,  and  no  irritation  of  the  hip  oc- 
curred.   This  improvement  was  made  about  1800. 

To  remed}'  the  defective  action  of  the  band  at  the  foot,  he  added  a  transverse 
foot-piece,  over  the  end  of  which  the  extending  band  was  passed,  which  made 
traction  in  line  with  the  shaft  of  the  femur.  These  improvements  greatly  in- 
creased the  efficiency  of  the  splint  and  added  to  the  popularity  of  the  treatment 
in  the  straight  position.  Dorsey  says :  "  I  have  for  twelve  or  fourteen  years  vnt- 
nessed  the  effect  of  this  mode  of  treatment  in  the  Pennsylvania  Hospital,  where 
more  accidents  are  admitted  than  in  any  other  uistitution  in  America,  and  I  am 
safe  in  asserting  that  the  success  of  the  practice  has  been  sm'passed  by  that  of 
no  other  hospital  in  the  world."  He  admits  that  some  surgeons  have  become 
dissatisfied  with  this  mode  of  treatment,  owing  to  the  excoriations  caused  by  the 
bands  especially  on  the  foot. 

It  was  in  this  particular  feature  of  extension  and  comiter-extension  that 
American  surgeons  perfected  the  method  of  treatment  of  fractures  of  the  femur 
in  the  straight  position.    In  1S61  Dr.  Gurdon  Buck,  of  Xew  York,  published  an 
^j,^  account  of  the  method  of  treating  fractures  of 

the  thigh  in  the  New  York  Hospital,  with  illus- 
trations. This  was  the  most  important  contri- 
bution that  had  to  this  time  been  made,  as  it 
remedied  the  great  defects  of  the  methods  hith- 
erto employed  to  effect  extension.  "  Buck's  ex- 
tension" is  too  well  known  to  the  students  of 
surgery  to  requii'e  explanation.  It  is  sufficient 
to  state  that  its  publication  was  the  culmination 
of  a  century  of  persistent  effort  on  the  part  of  the 
most  reputable  surgeons  of  this  country  and 
'   ^^  -~  Europe. 

Fig.  21. — Gurdon  Buck  (1S07-1S77). 

Gurdon  Buck  (1807-77)  was  born  in  New  York 
City,  yiay  4tli,  1S07.  He  graduated  in  medicine  from  the  College  of  Physicians 
and  Surgeons,  New  York,  in  1S30,  and  entered  the  Xew  York  Hospital  as  a  member 
of  the  resident  staff,  serving  by  preference  on  the  medical  division.  In  1833  he  went 
abroad  and  spent  two  years  in  the  hospitals  of  Paris,  Berlin,  and  A'ienna.  On  his 
return  he  located  in  Xew  York,  and  in  1837  was  appointed  one  of  the  visiting  sur- 


INTRODUCTION.  53 

geons  of  the  New  York  Hospital,  a  position  which  he  held  until  his  death,  a  period  of 
forty  years.  During  his  connection  •with  this  hospital  it  received  most  of  the  surgi- 
cal cases  of  the  city,  and  its  surgical  staff  was  constituted  of  the  most  eminent 
surgeons  of  New  York.  He  was  appointed  surgeon  of  St.  Luke's  Hospital  on  its 
organization,  and  subsequently  occupied  the  same  position  in  the  Presbyterian  Hos- 
pital. Dr.  Buck  was  a  most  painstaking  and  successful  practitioner  and  made  im- 
provements in  many  branches  of  surgery,  as  in  the  operation  for  bony  ankylosis  at 
the  knee-joint,  in  the  treatment  of  oedema  glottidis,  and  in  lithotomy  and  lithotrity. 
He  was  also  greatly  interested  in  plastic  surgery,  and  published,  in  1876,  a  mono- 
graph entitled  "Conintwiions  to  Reparative  Surgery."  But  the  apparatus  which 
he  devised  for  the  application  of  traction  in  the  treatment  of  fractures  of  the  femm: 
will  long  be  regarded  as  his  most  useful  contribution  to  the  practice  of  surgery.  He 
died  March  6th,  1877. 

Lithotomy  was  an  operation  of  the  first  importance  during  the  eighteenth 
century,  and  tlie  various  methods  of  procedure  were  subjects  of  endless  discus- 
sion. American  surgeons  who  were  educated  abroad  returned  to  practise  in  this 
country,  ambitious  to  gain  reputation  as  successful  lithotomists.  Many  became 
good  operators  and  some  attained  an  eminence  equal  to  that  of  the  most  reputable 
lithotomists  abroad.  Dr.  John  Jones,  of  New  York,  had  a  wide  reputation  as  a 
successful  lithotomist  as  early  as  1760.  Physick,  of  Philadelphia,  was  not  only  a 
successful  operator,  but  he  improved  the  gorget.  Jameson,  of  Baltimore,  was 
a  skilful  operator  and  advocated  healing  the  wound  by  first  intention  by  placing 
the  patient  on  his  side,  with  a  catheter  retained  in  the  bladder.  Dr.  Benjamin 
W.  Dudley,  of  Kentucky,  became  famous  for  the  large  number  of  operations 
which  he  performed,  amounting  to  two  hundred  and  twenty-five,  and  for  his 
great  success,  having  one  hundred  consecutive  cases  without  a  death.  But  in  the 
matter  of  numbers.  Dr.  John  P.  Mettauer,  of  Virginia,  excelled  him,  having  a 
record  of  four  hundred  cases. 

In  1824-25,  according  to  Jameson,  of  Baltimore,  some  of  the  most  distin- 
guished surgeons  of  America  performed  Civiale's  operation  of  "  lithontrity "  as 
a  substitute  for  lithotomy,  "  in  all  which  attempts  there  were  complete  failures." 
The  operation  was,  however,  subsequently  advocated  by  Randolph,  Gibson, 
Nathan  R.  Smith,  and  others,  under  the  title  "lithotripsy,"  but  it  did  not  sup- 
plant the  older  operation  of  lithotomy. 

In  the  progress  of  American  practice  both  lithotomy  and  lithotripsy  were 
destined  to  be  supplanted.  Bigelow,  impressed  with  the  great  distensibility  of 
the  urethra  as  shown  by  Otis's  experiments,  began  to  use  much  larger  evacuating 
tubes  in  the  operation  of  lithotrity,  with  the  result  of  being  able  to  remove  much 
larger  fragments  of  the  stone  than  formerly,  and  of  thus  reducing  both  the  num- 
ber of  operations  and  the  length  of  time  of  each  trial.  The  new  operation  was 
gradually  perfected  under  the  title  of  " litholapaxy "  (evacuation),  and  it  has 
largely  superseded  all  other  methods  of  removing  calculi  from  the  urinary 
bladder. 


54  AMERICAN  PRACTICE  OF  SURGERY. 

"Hip-joint  disease"  was  a  fatal  or  a  crippling  affection  of  childhood  which 
surgeons  regarded  as  helpless  and  hopeless  by  any  method  of  treatment  known 
prior  to  the  year  1800.  But  American  surgeons  have  stricken  hip-joint  affections 
from  the  category  of  incurable  diseases  and  placed  it  among  the  more  simple  and 
curable  forms  of  sickness  peculiar  to  childhood.  The  method  of  treatment  was 
determined  after  careful  study  of  the  pathological  conditions  of  the  hip-joint  by 
three  surgeons  at  different  periods.  The  history  of  their  work  admirably  illus- 
trates the  process  of  evolution  of  practice  based  on  scientific  principles.    . 

Dr.  Physick  returned  from  Europe  a  student  of  scientific  surgery  as  taught 
by  his  preceptor,  Hunter.  One  of  these  principles  was  that  rest  is  the  first  and 
essential  factor  in  the  correct  treatment  of  inflammation.  He  applied  that  prin- 
ciple to  the  treatment  of  hip-joint  disease,  about  the  year  1800,  in  the  following 
manner:  He  employed  "a  splint  properly  carved  so  as  to  be  adapted  to  the 
irregular  size,  shape,  and  position  of  the  diseased  hip-joint,  thigh,  and  leg.  It 
must  also  be  carved  so  as  to  fit  the  principal  part  of  the  same  side  of  the  trimk. 
The  whole  must  be  long  enough  to  extend  nearly  half  way  round  the  parts  to 
which  it  is  applied.  In  those  cases  in  which  the  thigh  is  bent  upon  the  pelvis  and 
the  leg  upon  the  thigh  at  the  knee  joint,  the  surgeon  must  by  no  means  attempt 
to  force  the  limb  into  a  straight  splint.  .  .  .  The  splint  must  be  made  angular 
at  those  parts  so  as  to  adapt  itself  to  the  exact  position  of  the  limb,  however 
crooked  it  may  be.  After  the  patient  has  worn  a  splint  of  this  shape  for  some 
time,  the  inflammation  and  swelling  become  so  much  relieved  that  the  limb  can 
be  placed  in  a  much  straighter  position;  and  now  it  becomes  necessary  to  have 
a  second  splint  constructed,  which  will  adapt  itself  to  the  altered  condition  of 
the  parts." 

Randolph,  Physick's  son-in-law,  makes  the  following  statement  of  the  results 
of  the  new  method  of  treatment  which  imperfectl}^  secured  rest  to  the  inflamed 
joint:  "The  success  which  Professor  Physick  has  met  with  from  his  mode  of 
treating  hip-joint  disease  has  been  so  highly  encouraging  as  to  induce  him  to  be- 
lieve that  he  can  effect  a  cure  in  all  recent  cases,  and  many  even  of  long  standing, 
provided  the  joint  be  not  disorganized." 

The  next  step  of  progress  was  the  cure  of  the  " disorganized"  cases.  In  1853 
Dr.  Alden  March,  of  Albanj-,  N.  Y.,  published  the  results  of  a  series  of  studies  in 
the  pathological  museums  of  this  country  and  Europe,  for  the  purpose  of  deter- 
mining the  condition  of  the  hip  joint  in  advanced  disease.  His  conclusion  was 
that  the  pressure  of  the  two  inflamed  joint  surfaces  led  to  destructive  ulceration 
of  the  cartilages,  and  his  practical  inference  was  that  if  traction  of  the  limb  were 
added  to  fixation  of  the  jomt,  sufficient  to  relieve  the  pressure  of  the  head  upon 
the  surface  of  the  acetabulum,  not  only  would  ulceration  be  prevented,  but  cases 
where  ulceration  already  existed  might  be  cured.  To  meet  this  indication  he 
applied  the  long  splint,  as  in  fracture  of  the  thigh,  with  extension  and  counter- 
extension.    The  result  was  immediate  relief  to  the  pain  and  final  recovery  of 


INTRODUCTION.  55 

the  more  intractable  cases.  Greatly  as  this  method  improved  the  treatment  of 
Physick  and  enlarged  the  number  of  curable  cases,  there  was  still  a  class  of  feeble 
patients  who  could  not  bear  the  long  confinement  and  large  suppuration  that 
followed  the  necrosis  of  the  head  of  the  femur,  and  eventually  succumbed  to 
exhaustion. 

The  final  question  in  the  problem  of  treating  hip-joint  disease  was,  therefore, 
How  can  fixation  of  the  ■  oint  and  traction  of  the  leg  be  effected  while  the  patient 
is  allowed  to  walk?  The  clew  to  the  answer  was  given  by  Dr.  Henry  G.  Davis, 
a  surgeon  of  great  inventive  skill,  of  Worcester,  Mass.,  in  1860.  He  devised  a 
splint  which  imperfectly  effected  the  object,  but  which  suggested  to  those  en- 
gaged in  that  special  field  of  work  the  proper  apparatus.  Davis's  splint  espe- 
cially impressed  Dr.  Lewis  A.  Sayre,  of  New  York,  who  was  devoting  much  at- 
tention to  this  disease,  and  who  states  that  he  had  long  recognized  the  impor- 
tance of  an  appliance  that  would  secure  fixation,  traction,  and  ability  to  walk, 
and  endeavored  to  construct  such  an  apparatus,  but  did  not  succeed.  On  ex- 
amining Davis's  splint,  Sayre  readily  discovered  not  only  the  essential  features 
of  a  rightly  constructed  hip  splint,  but  he  detected  the  real  cause  of  the  failure 
of  the  inventor  to  meet  conditions  necessary  to  success.  He  immediately  under- 
took to  construct  a  splint  which  would  meet  the  indications  now  so  apparent  to 
him,  and  the  result  was  a  splint  which  has  since  been  known  by  his  name  and 
which  is  the  perfection  of  surgical  art.  As  a  teacher  and  author,  Sayre  so  clearly 
and  persistently  demonstrated  and  illustrated  the  scientific  treatment  of  hip- 
joint  disease  that  he  compelled  the  profession  to  adopt  the  new  method. 

The  result  of  this  half-century  of  stvidies  relating  to  hip-joint  disease  is  in 
the  highest  degree  creditable  to  American  surgeons.  The  class  of  children  that 
at  the  beginning  of  this  period  died  after  years  of  intense  suffering,  confined 
to  their  beds,  are  to-day  met  on  the  streets,  at  school,  and  on  the  playgrounds, 
in  the  enjoyment  of  healthy  activity.  A  death  from  hip-joint  disease  is 
unknown  in  mortuary  statistics. 

Orthopedic  surgery,  as  a  specialty,  had  its  origin  in  this  country  in  the  clin- 
ical lectures  of  Dr.  William  Detmold  (1808-1900),  of  New  York.  He  was  a 
native  of  Hanover,  Germany,  a  graduate  of  the  University  of  Goettingen,  and  a 
pupil  of  the  famous  orthopedist,  Stromeyer.  He  located  in  New  York  City  in 
1837,  and  devoted  himself  to  the  practice  of  orthopedic  surgery.  For  the  purpose 
of  giving  instruction  in  this  specialty  he  established  a  public  clinic,  and  gave 
courses  of  lectures  which  were  largely  attended  by  medical  students  and 
practitioners.  He  was  a  skilful  operator  and  introduced  Stromeyer's  method 
of  tenotomy,  which  he  practised  with  the  greatest  freedom.  Though  Detmold 
discontinued  his  clinics  prior  to  1860  and  rarely  published  papers,  it  was  through 
the  influence  of  his  teaching  that  the  first  impulse  was  given  to  an  interest  in 
orthopedia,  which  resulted  finally  in  raising  it  to  the  position  of  a  distinct  branch 
of  surgical  practice. 


56 


MCERICAX  PRACTICE  OF  SURGERi'. 


1  /% 


-yvaHam  Detmold  (ISOS- 
1900). 


Detmold   as  a  teacher  of  orthopedia  was  succeeded  by  Dr.  Lewis  A.  Sayre, 
then  an  enthusiastic  young  surgeon  who  was  devoting  himself  to  the  treatment 
of  cases  of  deformity.      As  one  of  the  founders  of  the  Bellevue  Hospital  Medical 
_,_^  College,  1861,  he  urged  the  establishment  of  a 

"°°' '  it.  professorship  of  orthopedia,  and  on  its  creation 

he  was  appointed  to  the  position,  the  first  in  this 
covmtrj'.  Saj're's  annual  course  of  lectures  gave 
a  powerful  impulse  to  the  study  and  practice 
of  orthopedic  surger}^  throughout  the  entire 
country.  His  attractive  personality,  his  resist- 
less enthusiasm,  his  vast  resources  for  clinical 
illustrations  afforded  by  Bellevue  Hospital,  and 
his  bold  and  often  brilliant  operations,  inspired 
students  and  practitioners,  gathered  from  all 
parts  of  the  United  States,  with  a  genuine  de- 
termination to  practise  orthopedia.  The  in- 
fluence of  Sayre's  teaching  was  greatly  increased 
bj'  the  publication  of  his  lectures  in  1876,  which  formed  a  complete  treatise  on 
orthopedic  practice.  Though  many  surgeons  occasionally  performed  operations 
for  deformities,  and  frequently  papers  were  published  narrating  individual  cases 
and  methods  of  treatment  by  apparatus,  it  was  not  until  the  Bellevue  school 
had  created  a  professorship  of  orthopedia,  and  Sa}Te  had  given  to  that  profes- 
sorship the  character  and  importance  of  a  special 
branch  of  surgical  education,  that  orthopedia  as- 
sumed the  position  of  a  specialty  in  sm'gical 
practice  in  this  coimtry. 

Lewis  Albert  SajTe  (1S29-1900)  was  a  native 
of  New  Jersey  and  a  graduate  of  Transylvania 
University,  Kentucky.  He  studied  medicine  in 
New  York  City  and  graduated  from  the  College 
of  Physicians  and  Surgeons  in  1842.  In  the  same 
year  he  was  appointed  prosector  to  the  chair  of 
surgery  in  that  institution,  a  position  which  he 
held  until  1852.  In  1853  he  was  appointed  one  of 
the  visiting  surgeons  of  Bellevue  Hospital.  In 
1861  he  was  one  of  the  founders  of  Bellevue  Hospital 
Medical  College,  and  at  his  suggestion  the  professor- 
ship of  orthopecha  was  established,  which  was  subsequently  assigned  to  him.  He  re- 
tained this  position  until  1897,  when  ill  health  compelled  him  to  retire.  He  died 
in  1900. 

GyncECology  as  a  special  branch  of  operative  surgery  had  its  origin  in  the  ex- 
perimental work  of  Dr.  J.  Marion  Sims.  "  Silver  as  a  suture  is  the  great  surgical 
achievement  of  the  nineteenth  century,"  was  the  declaration  of  this  pioneer 


Fig.  23. — Lewis  Albert  Saj-re 
(1S29-1900). 


INTRODUCTION.  57 

surgeon  in  his  anniversary  discourse  before  tlie  New  York  Academy  of  Medicine 
in  1S57.  In  this  discourse  Sims  describes  at  length  and  eloquently  two  of  the 
most  important  events  in  the  history  of  the  American  practice  of  surgery,  viz., 
the  introduction  of  silver  wire  as  a  suture,  and  the  method  of  curing  vesico- 
vaginal fistula.  The  two  discoveries  were  the  result  of  a  single  course  of  experi- 
mental studies,  "conducted,"  as  the  author  states,  "on  the  principles  of  a  ra- 
tional inductive  philosophy."  The  original  purpose  and  object  of  Sims  was  the 
cure  of  vesico-vaginal  fistula.  After  repeated  failures  and  a  careful  study  of 
everything  connected  with  the  operation  that  might  contribute  to  his  want  of 
success,  he  was  finally,  after  four  years  of  patient  effort,  led  to  the  conclusion 
that  the  silk  suture  was  the  cause  of  failure. 

Instead  of  abandoning  his  enterprise,  he  turned  his  attention  to  the 
solution  of  another  problem,  apparently  more  difficult  than  the  one  on 
which  he  had  expended  so  much  time  and  study.  The  question  now  to  be 
settled  was,  AVhat  material  can  be  used  for  suture  that  will  not,  like  silk,  act 
as  a  seton?  He  had  read  the  experiments  of  Levert,  of  Mobile,  Ala.,  made  in 
1829,  at  the  suggestion  of  Physick,  which  proved  that  wire  or  lead  caused  no 
irritation,  and  also  the  statement  of  Mettauer,  of  Virginia,  that  he  had 
used  lead  wire  in  operations  with  success.  Sims  had,  in  fact,  used  lead  wire 
in  his  experiments,  but  without  success,  and  therefore  he  turned  to  silver  as 
offering  more  advantages  than  other  metals.  He  operated  with  silver  wire  on  the 
21st  of  June,  1849,  upward  of  three  years  after  his  first  experimental  operation, 
and  with  entire  success. 

The  value  of  that  operation  in  the  relief  of  human  suffering,  by  the  powerful 
impulse  which  it  gave  to  operative  surgery,  can  never  be  estimated.  Sims  first 
published  the  details  of  the  operation  in  1852. 
It  established  the  specialty  of  "gynaecology,"  of 
which  Sims  is  the  founder,  but  in  the  comprehen-  ( 

sive  scope  of  his  work  he  was  a  general  surgeon. 


J.  Marion  Sims  (1813-83)  was  born  in  South 
Carolina,  January  25th,  1813.  He  graduated  in 
medicine  at  Jefferson  Medical  College  in  1835,  and 
located  in  Montgomery,  Ala.  In  1853  he  removed 
to  New  York,  where  he  was  successful  in  establish- 
ing the  Woman's  Hospital,  in  which  he  practised 
gyna'cology,  clinically,  rendering  popular  his  opera- 
tion for  the  cure  of  vesico-vaginal  fistula.  He  re- 
peatedly visited  the  European  capitals,  where  he  per-  yig.  24, j.  Marion  Sims 

formed  his  special  operations,  and  received  honors  (1813-1SS3). 

and  decorations  from  the  French,  Italian,  Spanish, 

and  Belgian  Governments.  He  invented  many  instruments  adapted  to  the  opera- 
tions which  he  was  accustomed  to  perform.  He  was  in  Paris  at  the  breaking  out  of 
the  Franco-Prussian  War,  and  was  made  surgeon-in-chief  of  what  was  called  the 


58  AMERICAN  PRACTICE  OF  SURGERY. 

"Anglo- American  Ambulance  Corps,"  composed  of  eight  Americans  and  eight  Eng- 
lishmen. This  organization  was  at  the  battle  of  Sedan  and  was  assigned  to  duty  in 
connection  with  a  large  hospital  where  upward  of  twenty-six  hundred  wounded  were 
treated.  Dr.  Sims  continued  his  connection  with  the  Woman's  Hospital  from  its  or- 
ganization in  1855  to  his  death  in  1883. 

The  series  of  studies  which  have  terminated  in  the  scientific  treatment  of 
diseases  of  the  appendix  vermiformis  enters  largely  into  the  American  practice 
of  surgery.  The  initial  step  in  these  studies  was  taken  in  1856,  on  the  publica- 
tion of  a  paper  by  Dr.  George  Lewis,  entitled,  "  A  Statistical  Contribution  to  Our 
Knowledge  of  Abscess  and  Other  Diseases  Consequent  upon  Lodgment  of  For- 
eign Bodies  in  the  Vermiform  Appendix,  with  a  Table  of  Forty  Cases."  Lewis 
was  a  young  physician  of  New  York  who  had  recently  had  a  fatal  case  of  ap- 
pendicitis, and  at  my  suggestion  made  the  collection  of  cases  which  formed  the 
basis  of  his  paper.  Professor  Kelly,  of  Baltimore,  in  his  great  work  on  "  Appen- 
dicitis," speaks  of  Lewis's  paper  as  "by  far  the  most  complete  investigation  of 
the  diseases  of  the  appendix  up  to  the  date  of  its  publication." 

In  this  paper  Lewis  brought  prominently  to  the  attention  of  American  sur- 
geons the  operation  of  Hancock,  of  London,  who  in  1848  deliberately  opened  an 
abscess  formed  in  the  region  of  the  appendix  and  as  a  result  of  its  diseased  condi- 
tion, and  cured  his  patient.  Lewis's  paper  excited  great  interest  among  surgeons, 
and  led  Dr.  Willard  Parker,  of  New  York,  to  repeat  the  operation  of  Hancock. 
In  1867  Parker  published  the  histories  of  four  cases  on  which  he  had  operated, 
and  in  all  but  one  he  had  not  operated  until  fluctuation  was  distinct.  In  his 
early  cases  he  feared  to  operate,  as  he  was  uncertain  of  the  diagnosis,  but  in  one 
case  he  ventured  to  operate  in  the  early  stage  of  the  disease,  and  saved  his 
patient.  He  did  not,  however,  advocate  an  early  operation,  but  advised  a 
delay  of  five  days,  as  a  rule,  in  order  that  it  might  be  determined  whether 
suppuration  had  occurred,  believing,  as  I  often  heard  him  remark,  that  an 
operation  was  required  only  when  it  was  certain  that  pus  had  formed.  Pro- 
fessor Kelly  states  of  Parker's  work:  "From  the  date  of  his  teaching  opera- 
tive treatment  of  appendicitis  began  an  evolution  which  ended  in  the  revolution 
of  surgery." 

But  Parker's  operation  only  sought  the  evacuation  of  pus,  as  in  opening  an 
ordinary  abscess,  the  offending  gangrenous  appendix  being  left  in  the  wound. 
The  next  step  was  the  removal  of  the  appendix,  which  was  done  in  this  country 
in  May,  1886,  at  Roosevelt  Hospital,  New  York,  by  Dr.  R.  J.  Hall.  This  opera- 
tion was  only  an  incident  in  the  case .  The  next  step  in  advance  was  to  be  the 
excision  of  the  appendix  as  a  necessary  part  of  the  operation.  Parker's  opera- 
tion was  performed  from  time  to  time,  and  in  1875  Gouley  tabulated  twenty- 
five  cases.  There  was  a  reduction  of  mortality  from  forty-seven  per  cent  in  1867 
to  fifteen  per  cent  in  1882.  The  removal  of  the  appendix  as  a  necessary  part  of 
the  operation  was  not,  however,  undertaken  until  1887,  when  Dr.  Thomas  G. 


INTRODUCTION.  59 

Morton,  of  Philadelphia,  deliberatelj'  planned  and  executed  its  removal,  thus 
perfecting  Parker's  operation. 

Many  questions  still  remained  unsettled,  especially  as  to  the  diagnosis,  the 
■cases  requiring  operation,  the  exact  time  of  operating,  and  the  method  of  pro- 
cedure. These  questions  were  finally  A'ery  definitely  settled  by  two  remarkably 
able  scientific  papers.  The  author  of  the  first  was  Dr.  R.  J.  Fitz,  of  Boston, 
whose  article,  "On  Perforative  Inflammation  of  the  Vermiform  Appendix,"  ap- 
peared in  1886 ;  and  so  thoroughly  were  these  doubtful  questions  discussed  and 
determined  that  the  paper  has  been  pronounced  an  "epoch-making  memoir." 
Professor  Kelly  says  that  Fitz  "has  done  more  than  any  single  individual  to 
bring  about  a  right  understanding  of  the  morbid  conditions  affecting  the  vermi- 
form appendix."  Again  he  refers  to  Fitz's  work  as  follows:  "The  time  was  ripe, 
the  man  appeared,  and  surgeons,  needing  but  the  assurance  of  safety,  gratefully 
accepted  this  transfer  from  the  domain  of  internal  medicine,  and  began  with 
alacrity  to  develop  the  operative  procedure." 

The  paper  of  McBurney,  published  in  1889,  was  a  critical  review  of  all  ques- 
tions relating  to  the  operation,  and  its  conclusions  determined  the  details  of 
procedure  with  so  much  precision  that  there  have  been  only  minor  changes  in 
the  methods  which  he  prescribed.  Thus,  commencing  with  the  investigations  of 
Lewis  and  the  tentative  operations  of  Parker,  and  terminating  with  the  scientific 
inductions  of  Fitz  and  McBurney,  in  their  classical  papers,  have  American  sur- 
geons established  the  proper  treatment  of  inflammatory  affections  of  the  appen- 
dix vermiformis. 

It  has  not  been  our  purpose  to  notice  the  achievements  of  individual  sur- 
geons except  as  they  have  resulted  in  important  reforms  in  practice.  But  there 
have  been  instances  where  surgeons  have  performed  acts  or  adopted  methods  to 
meet  conditions  hitherto  unknown  to  them,  which  illustrate  American  ingenuity 
and  enterprise.    Several  of  these  examples  deserve  notice. 

Amputation  at  the  shoulder  joint  was  introduced  into  practice  during  the 
eighteenth  century  by  French  surgeons.  The  first  operation  in  this  country  was 
performed  by  Dr.  John  Warren,  of  Boston,  as  early  as  1781.  Dr.  Warren  had 
had  a  large  experience  in  operative  surgery  during  the  Revolutionary  War. 
The  operation  was  performed  in  the  Military  Hospital  at  Boston,  where  Dr. 
Warren  was  giving  lectures  to  physicians  and  students.  The  details  of  the  opera- 
tion were  not  published,  but  it  was  successful. 

In  1792  Dr.  Nathan  Smith  trephined  hone  for  the  cure  of  an  abscess.  The 
patient  was  aged  nine  years;  there  was  a  collection  of  matter  in  the  thigh,  ex- 
tending from  above  the  knee  nearly  to  the  trochanter.  An  incision  was  made 
from  near  the  knee  joint  upward  eight  inches;  a  large  discharge  of  pus  took 
place,  and  the  bone  was  found  denuded  of  its  periosteum  two-thirds  of  its  length. 
He  determined  to  wait  and  see  if  granulations  would  appear  on  the  denuded 


60 


AMERICAN  PRACTICE  OF  SURGERY. 


bone;  but  as  they  did  not,  and  the  bone  became  of  a  dark  color,  he  decided  to 
remove  a  portion  in  such  manner  as  to  go  through  the  dead  part,  let  that  be 
more  or  less.  He  used  a  trephine — ''the  round  saw  employed  in  operating  on 
the  skull" — nearly  in  the  centre  of  the  denuded  part,  and  removed  a  piece  of 
bone  down  to  the  medullary  substance.  Purulent  matter  issued  in  pulsations 
from  between  the  bone  and  the  medullary  substance.  In  a  few  days  "  the  bone, 
which  was  a  pearly  white,  a  little  verging  to  brown,  where  exposed  to  the  exter- 
nal air,  changed  its  appearance,  assuming  a  carmine  color,  and  finally  recov- 
ered, with  no  other  loss  of  substance  than  a  thin  scale." 

Previous  to  the  year  1806,  amputation  at  the  hip  joint  had  been  performed 
but  once  by  British  surgeons,  and  in  that  case  the  operation  resulted  fatally. 
In  that  year  Dr.  Walter  Brashear,  of  Kentucky,  performed  this  amputation 
successfully.  The  operation  consisted  of  two  procedures:  First,  the  surgeon 
amputated  at  the  middle  third  of  the  thigh  in  the  usual  way  and  ligated  the 
vessels;  second,  he  made  an  incision  on  the  outside  of  the  limb  from  the  point 

of  previous  operation  to  the  hip  joint.  Then  he 
detached  the  soft  parts  from  the  bone  and  disar- 
ticula,ted  it.    The  patient  made  a  good  recovery. 

Walter  Brashear  (1776-1S09)  was  a  native  of 
the  State  of  Marj-land.  He  received  his  education 
at  the  Transylvania  University,  Kentucky.  He 
attended  a  course  of  lectures  at  the  University  of 
Pennsylvania  and  then  travelled  extensively;  on 
his  return  he  engaged  in  merchandise  for  twelve 
j^ears,  when  he  resumed  practice  at  Bardstown, 
where  he  perfonned  the  amputation.  He  removed 
soon  after  to  Lexington,  Ky.,  and  after  a  few  years 
of  successful  practice  he  retired  to  the  State  of 
Louisiana.     He  was  not  a  graduate  in  medicine. 

Fig.  25.— Walter  Brashear  (1776-        He  died  in  1809. 
1809). 

The  first  applications  of  a  ligature  to  the 
common  carotid  were  for  the  arrest  of  hemorrhage  in  open  wounds.  In  the 
performance  of  this  operation  American  surgeons  were  anticipated  eighteen  days 
by  British  surgeons.  On  the  4th  of  November,  1803,  Dr.  JIason  Fitch  Cogswell, 
of  Hartford,  Conn.,  attempted  to  remove  a  tumor  which  developed  in  the  parotid 
gland  and  parts  adjacent;  in  the  progress  of  the  dissection  the  tumor  had  to  be 
separated  from  the  carotid  artery,  which  it  surrounded.  The  effort  failed,  and 
the  operator  placed  a  ligature  around  the  artery,  which  he  then  severed.  The 
case  progressed  favorably,  the  ligature  separating  on  the  fourteenth  da}^,  but  on 
the  twentieth  day  one  of  the  anastomosing  arteries  under  the  forepart  of  the  jaw 
began  to  bleed,  and,  no  effort  being  made  to  check  it  for  a  considerable  period, 
the  loss  of  blood  was  so  great  that  the  patient  sank  and  died. 

The  operation  of  Dr.  Cogswell  was  entirely  original  with  him,  as  was  the 


INTRODUCTION. 


61 


second  case,  by  Dr.  Amos  Twitchell,  of  Keene,  N.  H.,  original  with  that  surgeon. 
This  case  was  one  of  sloughing  of  the  internal  carotid  following  a  gunshot  wound  ; 
the  patient  made  a  good  recovery.  This  operation  was  performed  on  the  eigh- 
teenth day  of  October,  1807. 

The  first  case  of  ovariotomy,  by  Dr.  Ephraim  McDowell,  of  Kentucky  (1771- 
1830),  was  deliberately  planned  and  executed  by  a  surgeon  who  had  never 
"seen  so  large  a  substance  extracted,  nor  heard  of  an  attempt  or  success 
attending  any  operation,  as  this  required."  The  woman  rode  sixty  miles  on 
horseback  to  the  place  of  operation.  The  operation  was  performed  in  Decem- 
ber, 1809,  by  an  "incision  about  three  inches  from  the  musculus  rectus 
abdominis,  on  the  left  side,  continuing  the  same  nine  inches  in  length, 
parallel  with  the  fibres  of  the  above-named  muscle,  extending  into  the  cavity 
of  the  abdomen,  the  parietes  of  which  were  a  good  deal  contused,  which  we 
ascribed  to  the  resting  of  the  tumor  on  the  horn  of  the  saddle  during  her 
journey.  The  tumor  then  appeared  full  in  view,  but  was  so  large  that  we 
could  not  take  it  away  entire.  We  put  a  strong  ligature  around  the  Fallopian 
tube  near  the  uterus;  we  then  cut  open  the  tumor,  which  was  the  ovarium 
and  fimbrious  part  of  the  Fallopian  tube,  very  much  enlarged.  We  took  out 
fifteen  pounds  of  a  dirty,  gelatinous-looking  substance,  after  which  we  cut 
through  the  Fallopian  tube  and  extracted  the  sac,  which  weighed  seven  and 
a  half  pounds."  The  wound  was  closed  with 
interrupted  sutures  and  adhesive  strips  between 
them,  and  the  ligature  on  the  Fallopian  tube 
was  brought  out  of  the  lower  angle  of  the 
wound.  The  report  adds:  "In  five  days  I 
visited  her,  and,  moch  to  my  astonishment, 
fomid  her  engaged  in  making  up  her  bed." 
The  patient  returned  home  in  twenty-five  clays 
in  good  health. 

It  is  reported  that  the  operation  created  such 
public  opposition  that  a  mob  collected  around 
the  house  in  which  it  was  performed,  prepared 
to  attack  the  surgeon  if  he  failed.  An  account 
of  the  operation  was  published  several  years 
after  in  an  obscure  journal,  and  was  so  imperfectly  reported  as  to  be  discredited; 
hence  it  has  had  no  other  importance  than  an  historical  incident. 

Twelve  years  later,  in  1821,  Dr.  Nathan  Smith,  of  New  Haven,  Conn.,  per- 
formed the  operation  of  ovariotomy,  having  no  knowledge  of  any  previous  sim- 
ilar operation.  He  was  led  to  make  the  operation  from  his  observations  in  dis- 
secting the  body  of  a  patient  who  had  died  of  ovarian  dropsy  after  being  tapped 
seven  times.  The  sac  was  found  to  be  the  right  ovarium,  which  filled  the  whoJo 
abdomen,  but  it  adhered  to  no  part  except  the  proper  ligament,  which  waf  no 


Fig.  26. — Ephraim  McDowell 
(1771-1830). 


62  AMERICAN  PRACTICE  OF  SURGERY. 

larger  than  the  finger  of  a  man.  He  had  seen  two  other  autopsies  of  women  who 
suffered  from  ovarian  disease,  and  noticed  that  the  sacs  were  unattached,  except 
to  their  own  proper  hgaments.  He  inferred  that  while  the  tumor  remained 
movable  it  might  be  removed  with  a  prospect  of  success.  His  operation  was  as 
precise  in  all  its  details  as  the  most  modern  method.  The  external  incision  be- 
gan about  an  inch  below  the  umbilicus,  directly  in  the  linea  alba,  and  extended 
downward  three  inches;  the  sac  was  evacuated  with  trocar  and  cannula  and  then 
drawn  out,  bringing  with  it  a  considerable  portion  of  omentum,  which  was  sepa- 
rated and  the  bleeding  vessels  tied  with  leather  ligatures.  When  the  ovarian 
ligament  was  brought  out  it  was  cut  off,  two  small  arteries  were  tied  with  leather 
ligatures,  and  the  stump  was  returned;  some  adhesions  of  the  sac  were  separated 
and  the  mass  was  removed.  The  incision  was  closed  with  adhesive  plaster  and 
a  bandage  applied  over  the  abdomen.  No  unfavorable  symptoms  occurred,  and 
in  three  weeks  the  patient  was  able  to  walk  about. 

Smith's  well-devised  and  executed  operation  hadno  proper  publicity,  and  hence 
it  had  no  effect  in  introducing  a  new  procedure  into  practice,  but,  like  McDowell's 
operation,  simply  illustrates  the  great  abilities  of  the  individual  surgeon. 

Surgery  of  the  abdominal  cavitj^  began  to  attract  attention  toward  the 
close  of  this  period,  but  the  few  operations  that  were  practised  were  incidental 
and  accidental  rather  than  deliberative.  There  had  been  some  preparatory- 
work  done,  as  in  the  experiments  on  the  treatment  of  wounds  of  the  intestines. 
As  early  as  1805  Dr.  Thomas  Smith  published  a  thesis  presented  to  the  faculty 
of  the  Medical  Department  of  the  University  of  Pennsylvania,  entitled,  "On 
Worinds  of  the  Intestines."  The  thesis  was  based  on  the  results  of  twelve  ex- 
periments on  dogs,  undertaken  to  prove  the  value  of  the  different  methods  of 
treatment  of  womids  of  the  intestines.  He  made  transverse  and  longitudinal 
v>-ounds,  divided  the  tube,  exsected  portions,  and  cut  away  triangular  sections. 
Pie  used  the  mterrupted  and  the  continuous  suture.  The  vivisections  were  very 
carefully  made  and  the  results  accuratelj^  stated.  This  paper  was  highly  cred- 
itable as  an  effort  to  determine,  at  that  early  day,  by  scientific  inquiries,  the 
proper  method  of  treating  wounds  of  the  intestines.  He  used  the  silk  suture, 
and  found  that  when  he  cut  the  thread  near  the  knot,  returned  the  bowel,  and 
permanently  closed  the  external  woimd,  he  had  better  results  than  in  cases 
\^■here  he  followed  the  common  practice  of  allowing  the  ends  of  the  suture  to 
depend  from  the  wound  for  the  purpose  of  removal  when  it  separated.  Con- 
trary to  the  prevailing  views,  he  found  that  longitudinal  wounds  healed  as 
promptly  as  transverse  wounds. 

Dr.  S.  D.  Gross,  then  professor  of  svn-gery  in  the  University  of  Louisville,  Ky., 
published  (1843)  his  monograph,  entitled,  "An  Experimental  and  Critical 
Inquiry  Into  the  Nature  and  Treatment  of  Wounds  of  the  Intestines."  The 
object  of  the  author  was  to  "inquire  into  the  process  employed  by  nature  in  re- 
pairing wounds  of  the  intestines,"  and  "particularly  to  determine,  if  possible. 


INTRODUCTION.  63 

the  value  of  the  more  important  methods  of  treatment  recommended  from  the 
time  of  Ramdohr  down  to  our  own." 

But  the  great  operations  of  ovariotomy  by  Dudley  and  Nathan  Smith  stood 
as  permanent  beacon  lights  for  half  a  century,  indicating  the  direction  of  the 
explorer  for  new  fields  of  conquest,  before  the  pioneer  appeared  who  dared  to 
penetrate  the  peritoneum  and  effectively  treat  the  viscera  which  it  invested. 
Dr.  J.  Marion  Sims,  guided  by  the  same  inductive  method  of  reasoning  and  in- 
spired by  the  scientific  spirit  which  characterized  his  introduction  of  silver  wire 
into  practice,  not  only  advocated  the  free  exposure  of  the  peritoneal  cavity  for 
the  purposes  of  surgical  operations,  but  he  boldly  led  the  way  in  his  operation 
for  gall  stones.  The  result  of  his  pioneer  work  has  been  the  almost  limitless  ex- 
pansion of  the  field  of  operative  surgery. 

Though  anaesthesia  was  introduced  into  the  practice  of  surger}'  in  1846,  and 
exerted  a  marked  influence  upon  its  evolution  during  a  quarter  of  a  century  of 
the  period  of  which  we  write,  it  was  not  until  antisepsis  had  united  its  marvel- 
lous energy  to  ansesthesia  that  the  American  practice  of  surgery  underwent  a 
complete  revolution.  We  have,  therefore,  reserved  a  sketch  of  the  historj^  of 
this  greatest  of  all  American  discoveries  to  the  close  of  the  formative  and  the 
beginning  of  the  practical  period,  when  through  the  combined  influence  of  these 
agencies  the  practice  of  surgery  was  placed  securel}'  on  a  scientific  basis. 

The  introduction  of  anaesthesia  into  the  practice  of  surgery  was  not  only  the 
most  notable  achievement  of  American  surgeons  at  that  time,  1846,  but,  in  its 
far-reaching  influence  upon  the  practice  of  surgery,  anaesthesia  has  proved  the 
most  important  evolutionary  force  hitherto  discovered.  The  story  of  the  strug- 
gle of  the  contestants  for  public  recognition  of  priority  in  the  discovery  of  ana?s- 
thesia  forms  one  of  the  saddest  and  most  revolting  chapters  in  the  history  of  the 
sciences.  So  fierce  and  relentless  was  the  conflict  that  three  of  the  four  claim- 
ants became  insane.  Two  of  the  latter  were  driven  to  suicide.  Standing  on  the 
vantage-ground  of  half  a  century  since  the  bitter  contest  closed,  we  are  in  a  po- 
sition to  determine  not  only  the  part  which  each  claimant  had  in  the  discovery 
of  anaesthesia,  but  to  whom  the  verdict  of  history  awards  the  merit  of  intro- 
ducing anaesthesia  into  the  practice  of  surgery. 

The  term  ancesthesia  was  suggested  by  Dr.  Oliver  Wendell  Holmes,  as  appears 
from  the  following  letter  to  Dr.  Morton,  dated  November  21st,  1846 :  "  Everybody 
wants  to  have  a  hand  in  the  great  discovery.  All  I  will  do  is  to  give  you  a  hint  or 
two  as  to  names,  or  the  name  to  be  applied  to  the  state  produced  and  to  the  agent. 
The  state  should,  I  think,  be  called  anaesthesia.  .  .  .  The  adjective  will  be  ana?s- 
thetic.    Thus  we  might  say  the  state  of  'anaesthesia,'  or  the  'anaesthetic  state.'" 

On  the  30th  day  of  March,  1842,  Dr.  Crawford  W.  Long,  of  Jefferson,  Jack- 
son County,  Ga.,  removed  a  small  glandular  tumor  from  the  neck  of  a  patient, 
who  had  been  rendered  completely  insensible  by  the   inhalation  of  sulphuric 


6^  •  AMERICAN  PRACTICE  OF  SURGERY. 

ether.  The  operation  was  completely  successful,  as  the  patient  was  not  con- 
scious of  the  procedure  and  made  a  good  recoverJ^  This  was  the  first  case  of  the 
employment  of  an  anesthetic  in  the  practice  of  surger}^  recorded  in  modern  sur- 
gical literature.  It  was  not  an  accidental  occurrence,  but  the  result  of  careful 
observation  and  experiment  in  a  truly  scientific  spirit.  Dr.  Long  had  witnessed 
the  effects  of  nitrous  oxide — laughing  gas — in  rendering  persons  insensible  to 
painful  injuries  when  under  its  influence,  and,  to  satisfy  himself  of  this  fact,  he 
took  the  gas  himself,  and  received  injuries  that  he  was  not  conscious  of  until  he 
recovered  from  the  effects  of  the  gas.  These  experiences  induced  him  to  under- 
take his  first  surgical  operation  while  the  patient  was  mider  the  influence  of  the 

anaesthetic.  Dr.  Long  continued  to  employ 
^  antesthetics  in  his  surgical   practice  for  seven 

years,  or  until  1849,  before  he  published  an 
:;:       „     '  account  of  his  discovery. 

Crawford  W.  Long  (1816-78)  was  born  on  the 

3d  day  of  November,  1816,  in  Danielsville,  Madison 

^^M  County,  Ga.    He  graduated  from  the  University  of 

■^^^  -^      Georgia  in  1835,  and  from  the  Medical  Department 

P'vi     of  the  Universit_v   of  Pemisylvania  in  1839.  He 

Jj^     began  the  practice  of  his  profession  at  Jefferson, 

I  ''C      Jackson  County,  Ga.    The  operations  which  he  per- 

l '"        formed  were  of  a  minor  character,  as  there  were 

no  hospitals  at  that  time  accessible  to  him.    He 

^°-  ^''■("^''^sf  ^'  -^^^  was  also  deprived  of  the  advantages  of  medical 

societies  and  medical  journals,  but  his  success  as  a 

surgeon  gave  him  a  local  reputation  of  the  highest  character.    He  died  on  the  16th 

day  of  June,  1878. 

On  the  11th  day  of  December,  1844,  Dr.  Horace  Wells,  a  dentist  of  Hart- 
ford, Conn.,  having  observed  that  persons  who  took  laughing  gas  and  received 
injuries  were  unconscious  of  pain  until  they  recovered  from  the  effects  of  the 
gas,  had  one  of  his  own  teeth  extracted  while  he  was  fully  under  the  effects  of 
the  gas,  and  experienced  no  more  pain  than  "the  prick  of  a  pin."  On  recover- 
ing, he  exclaimed:  "A  new  era  in  tooth  pulling!  It  is  the  greatest  discovery 
ever  made."  He  introduced  it  into  his  dental  practice  and  daily  extracted  teeth 
without  pain.  Impressed  with  the  value  of  his  discovery,  in  1845  Dr.  Wells  vis- 
ited Boston  for  the  purpose  of  giving  it  greater  publicity,  but  failed  in  awaken- 
ing an  interest  in  those  he  consulted.  It  is  alleged  that  he  attempted  the  use  of 
sulphuric  ether,  but  did  not  succeed  in  accomplishing  any  practical  results 
with  it. 

On  the  30th  day  of  September,  1846,  Dr.  W.  T.  G.  Morton,  a  dentist  of  Bos- 
ton, Mass.,  administered  sulphuric  ether  to  a  patient  and  extracted  a  tooth 
without  pain.    Morton  had  been  a  pupil,  and  subsequently  a  partner,  of  Wells, 


INTRODUCTION.  65 

and  through  the  medium  of  these  close  relations  the  former  had  become  famihar 
with  the  experiments  and  practice  of  the  latter  in  the  use  of  nitrous-oxide  gas  in 
dental  operations.  In  attempting  to  repeat  Wells's  methods  of  practice,  Morton 
found  difficulty  in  securing  a  supply  of  gas,  and  applied  to  Dr.  C.  T.  Jackson,  a 
chemist  of  Boston  and  his  former  instructor.  On  learning  what  use  Morton  was 
to  make  of  the  gas,  Jackson  suggested  the  use  of  sulphuric  ether,  which  would 
have  the  same  effect,  required  no  apparatus,  was  entirely  safe,  and  was  readily 
obtained.  It  was  on  this  advice  that  Morton  performed  the  operation  of  Sep- 
tember 30th.  In  the  belief  that  he  had  made  a  discovery  of  great  pecuniary 
value,  Morton  took  out  patents,  both  in  this  country  and  [in  Great  Britain, 
imder  the  name  "Letheon." 

On  the  16th  day  of  October,  1846,  Dr.  John  C.  Warren,  one  of  the  surgeons 
of  the  Massachusetts  General  Hospital,  removed  a  small  vascular  tumor  from  the 
neck  of  a  patient,  under  the  full  influence  of  the  "letheon,"  the  identity  of  which 
Morton  concealed  b}^  adding  to  the  ether  aromatic  oils.  The  operation  was  per- 
formed at  Morton's  request,  in  order  to  test  the  value  of  the  anaesthetic  in  sur- 
gical operations.  Though  the  trial  proved  entirely  successful,  the  effort  of  Morton 
to  conceal  the  true  nature  of  "letheon"  prejudiced  the  surgeons  against  its  fur- 
ther use  until  he  acknowledged  that  the  active  agent  in  the  preparation  was 
sulphuric  ether.  The  anassthetic  was  then  freely  tested  in  capital  operations, 
Dr.  Warren  resecting  a  lower  jaw  and  Dr.  Hayward  amputating  above  the  knee 
joint.  The  success  of  these  operations,  while  the  patients  were  under  the  influ- 
ence of  the  anesthetic,  was  so  complete  and  satisfactory  as  to  gain  the  applause 
of  not  only  the  eminent  operators  and  surgical  staff  of  the  hospital,  but  of  the 
entire  medical  fraternity  of  Boston.  The  Massachusetts  General  Hospital  at 
once  became  a  luminous  centre,  ushering  in  the  dawn  of  the  new  era  in  the  prac- 
tice of  surgerJ^  Scarcely  a  half  year  passed  before  its  rays  illuminated  every 
hospital  in  the  capitals  of  this  country  and  Europe,  and  anaesthesia  in  the  prac- 
tice of  surgery  was  imiversally  acknowledged  as  the  greatest  and  most  benefi- 
cent discovery  in  the  annals  of  science. 

Morton  subsequently  petitioned  Congress  for  an  allowance  from  the  public 
treasury  as  the  discoverer  of  anaesthesia  Ln  surgical  operations,  and  thus  brought 
under  public  discussion  the  question  of  priority.  The  friends  of  Long,  Wells,  and 
Jackson  appeared  before  the  committee  of  the  House,  to  whom  the  matter  was 
referred,  and  contested  Morton's  claims.  Congress  failed  to  take  action,  and  the 
contest  passed  unsettled  into  history. 

In  the  light  of  the  preceding  facts  we  conclude  that  Dr.  Crawford  W.  Long, 
a  surgeon,  first  used  ether  as  an  anaesthetic  in  the  practice  of  surgery,  but 
did  not  publish  the  fact  tmtil  others  had  independently  repeated  his  experiment. 
2.  Dr.  Horace  Wells,  a  dentist,  was  the  second  person  to  use  an  anaesthetic,  but 
limited  it  to  nitrous-oxide  gas  in  dental  operations.  3.  Dr.  W.  T.  G.  Morton,  a 
dentist,  experimented  to  find  an  anaesthetic  La  dental  operations,  and  was  led  to 


66  AMERICAN  PRACTICE  OF  SURGERY. 

use  sulphuric  ether  at  the  suggestion  of  Dr.  C.  T.  Jackson,  a  chemist.  Morton 
succeeded  so  well  that  he  concluded  that  he  had  made  a  discovery  of  great  pe- 
cuniary value,  and  obtained  patents.  In  order  to  give  it  publicity  and  repute  in 
the  profession,  he  solicited  Dr.  John  C.  Warren  to  use  it  in  the  Massachusetts 
General  Hospital  during  an  operation.  4.  Dr.  C.  T.  Jackson,  a  chemist,  merely 
suggested  that  sulphuric  ether  is  more  readily  used  as  an  anaesthetic  than  nitrous 
oxide. 

There  is  a  monument  standing  in  the  Public  Garden  of  Boston  on  which  is 
inscribed  the  verdict  of  history  as  to  the  honor  and  glory  of  introducing  anaes- 
thesia into  the  practice  of  surgery : 

To  commemorate  the  discovery  that  the  inhaling  of  ether  causes  insensi- 
bility to  pain,  first  proven  to  the  ivorld  at  the  Massachusetts  General 
Hospital  in  Boston,  October,  A.D.  MDCCCXLVI. 

Antisepsis  in  the  practice  of  surgery  had  its  origin  with  British  surgeons. 
The  principles  on  which  its  employment  is  based  were  scientifically  established 
by  Mr.  Lister  during  the  years  1870-75,  and  by  him  reduced  to  a  definite  system 
of  practice  which  has  been  universally  accepted.  But,  like  all  innovations  upon 
long-established  customs  which  are  revolutionary  in  their  operations,  antisepsis 
was  received  by  the  older  and  more  conservative  surgeons  of  Europe  with  doubt 
and  hesitation.  But  the  American  surgeons  who  visited  Edinburgh  and  wit- 
nessed the  practical  application  of  antiseptics  under  the  directions  of  Mr.  Lister, 
and  the  remarkable  healing  of  wounds  without  suppuration,  were  profoundly 
impressed  with  the  far-reaching  influence  of  the  discovery  upon  the  future  prac- 
tice of  surgery,  and  hastened  to  introduce  the  new  method  into  hospitals  at 
home.  The  announcement  of  the  results  of  antisepsis  in  the  treatment  of  wounds 
was  received  m  this  country  with  genuine  American  enthusiasm,  and  the  pre- 
scribed antiseptic  agents  were  immediately  placed  on  trial  in  scores  of  hospitals. 
The  results  justified  the  claims  of  visitors  to  the  wards  of  the  Edinburgh  surgeon, 
and  antisepsis  took  its  rightful  position  as  an  indispensable  factor  in  the  Ameri- 
can practice  of  surgery.  And  in  the  application  of  antisepsis  to  practice,  the 
surgeons  of  no  country  have  excelled  the  American  in  their  efforts  to  adapt 
means  to  an  end  in  the  construction  of  operating-rooms  and  their  equipment 
with  every  conceivable  device  to  secure  perfect  asepsis  of  the  patient,  the  sur- 
geon and  his  assistants,  the  instruments,  the  wound,  and  its  dressings.  In  hun- 
dreds of  hospitals  in  this  country  the  antiseptic  treatment  is  carried  out  with 
such  precision  of  details  as  to  eliminate  pus  in  operated  cases.  The  results  are 
simply  marvellous.  Operations  that  half  a  century  ago  were  unthought  of  and 
even  unthinkable  on  account  of  their  danger,  are  daily  performed  with  the  most 
absolute  success.     In  many  operations  which  once  had  a  high  death  rate  the 


INTRODUCTION.  67 

mortality  has  been  reduced  so  as  to  be  merely  nominal,  and  in  a  few  once  capital 
operations  the  death  rate  has  been  eliminated  from  the  record  altogether. 

In  the  year  1826  Professor  Sewall,  of  Colmiibia  College,  Washington,  D.  C, 
reviewing  the  progress  of  medicine  in  this  country  during  the  sixty  years  of  its 
then  national  existence,  spoke  in  the  following  eulogistic  terms:  "If  in  sixty 
years,  with  the  limited  means  we  have  possessed  and  with  all  of  the  difficulties 
we  have  had  to  encounter,  we  have  produced  the  best  system  of  medical  educa- 
tion, the  most  perfect  system  of  medical  police  that  has  been  exhibited  to  the 
world;  if  we  have  produced  some  of  the  best  practical  and  elementary  books, 
and  some  of  the  most  eminent  physicians  and  surgeons  of  any  age  or  country; 
.  .  .  what  will  be  our  advance  in  the  sixty  years  to  come?" 

Those  sixty  years  have  passed,  and  an  additional  score  of  years  have  been 
added  to  the  number,  and  how  insignificant  and  even  contemptible  appear  the 
system  of  medical  education,  the  medical  police,  and  the  medical  literature  of 
that  period!  Then  there  were  twenty  medical  colleges,  giving  instruction  an- 
nually to  about  two  thousand  students;  now  there  are  one  hundred  and  fifty- 
seven  medical  schools,  educating  upward  of  twenty-eight  thousand  students. 
Then  the  medical  police  was  limited  to  gratuitous  advice  to  the  civil  authorities; 
now  it  is  a  controlling  force  in  the  protection  and  promotion  of  the  public  health. 
Then  but  three  surgical  works  had  been  published  and  but  two  medical  period- 
icals were  regularly  issued ;  now  forty-five  native  surgical  works  were  published 
in  two  years  and  three  hundred  journals  are  regularly  issued.  Then  there  were 
three  fully  equipped  hospitals;  now  they  are  found  by  the  score  in  the  large 
cities,  and  scarcely  a  village  community  is  without  its  local  hospital. 

In  concluding  this  sketch  of  the  evolution  of  the  American  practice  of  surgery 
we  have  not  sought  to  magnify  the  achievements  of  individual  surgeons,  nor 
even  to  enumerate  what  must  be  regarded  as  notable  events  in  the  general  his- 
tory of  surgery,  except  so  far  as  such  achievements  and  events  illustrate  the  ele- 
mental conditions  and  forces  which  governed  its  progress  and  development. 
For  this  reason  we  have  dwelt  more  upon  the  special  features,  educational  and 
experimental,  of  the  early  periods  of  our  history  than  upon  the  triumphs  of  these 
modern  times,  which  are  but  the  fruitage  of  the  culture  of  the  past.  What  the 
American  practice  of  surgery  is  to-day  will  be  amply  illustrated  in  these  pages 
by  surgeons  whose  daily  duties  are  in  the  special  fields  of  which  they  are  the  his- 
torians. The  records  of  that  practice  will  justify  the  conclusion  of  Mr.  Erichsen 
in  the  paper  referred  to :  "I  know  no  country  in  which,  so  far  as  it  is  possible  to 
judge  from  contemporary  medical  literature,  there  is  so  widely  diffused  a  high 
standard  of  operative  skill  as  in  this  country." 


PART  I. 

SURGICAL  PATHOLOGY. 


INFLAMMATION. 

By  ALDRED  SCOTT   WARTHIN,  Ph.D.,   M.D.,  Ann  Arbor,  Michigan. 


I.  GENERAL  CONSIDERATIONS. 

1.  Inflammation  is  a  Pathological  Complex,  Essentially  Adaptive, 
Protective,  and  Reparative,  Constituting  the  Reaction  of  the  Body 
Cells  to  Injury,  either'  Direct  or  Referred.  , 

Experimental  and  comparative  pathology  have  given  us  a  broad  biologic 
conception  of  the  reaction  of  cells  to  injury.  From  the  lowest  forms  of  ani- 
mal life  up  through  the  higher  to  man  we  find  that  tissue  injury,  when  not  so 
severe  or  extensive  as  to  cause  the  death  of  the  individual,  excites  a  definite 
response  in  the  animal  organism.  No  matter  what  the  nature  of  the  harmful 
agent  ("irritant")  may  be,  this  reaction  on  the  part  of  the  damaged  organism, 
unicellular  or  multicellular,  is  in  its  essence  the  same ;  that  is,  it  is  at  founda- 
tion an  attempt  to  oppose  or  evade  the  irritating  agent,  to  counteract  its  harmful 
effects,  and  to  repair  the  damage  caused  by  it.  Naturally,  these  protective  and 
reparative  efforts  are  carried  out  somewhat  differently  in  the  case  of  different 
animals,  according  as  their  structure  is  simple  or  complex.  Likewise  the 
great  variety  of  injurious  agents  and  the  varying  conditions  under  which 
they  act  must  influence  the  course  of  the  reaction.  It  may  be  stated  also, 
in  the  beginning,  that  these  protective  and  reparative  processes  are  often 
inadequate  or  imperfect;  in  fact,  in  the  attempt  to  protect  itself  the  organ- 
ism may  inflict  further  damage  upon  itself,  even  to  such  an  extent  that  the 
death  of  the  individual  may  ensue.  In  spite  of  these  imperfections  the  essen- 
tial fact  remains — the  process  of  inflammation  is  at  bottom  protective  and 
reparative. 

In  the  case  of  unicellular  animals  the  protective  process  can  be  studied  in  its 
simplest  form.  In  such  an  animal  both  protective  and  reparative  functions  are 
reduced  to  the  basis  of  the  single  cell.  It  may  protect  itself  by  the  extrusion  or 
destruction  of  the  harmful  agent,  the  latter  event  being  brought  about  by  means 
of  intracellular  chemical  processes  akin  to  digestion;  while  cell  defects  due  to 
the  action  of  the  irritant  are  repaired  through  a  new  growth  of  cell  substance. 

In  multicellular  animals  the  division  of  labor  among  different  cell  groups 
results  in  the  assignment  of  protective  and  reparative  functions  especially  to 
certain  kinds  of  cells,  and  the  more  complex  structure  of  the  organism  necessi- 
tates a  much  more  elaborate  method  of  protection.     While   individual  cells 


72  AMERICAN  PRACTICE  OF  SURGERY. 

retain  to  a  greater  or  less  degree  the  individual  fimctions  of  the  unicellular  organ- 
ism, these  become  lessened  or  may  be  wholly  lost  as  the  cell  gains  in  specializa- 
tion. Accordingly,  in  the  higher  vertebrates  and  in  man  we  find  that  the 
removal  and  destruction  of  harmful  agents  are  effected  chiefly  by  wandering 
mesoblastic  cells,  lymphoid  tissue,  and  the  endothelium;  while  repair  is  chiefly 
brought  about  by  the  proliferation  of  fixed  connective-tissue  cells  and  endothe- 
lium. The  more  highly  developed  structure  of  the  multicellular  organism,  its 
complex  nutritive  mechanism,  and  the  important  part  played  in  the  body 
economy  by  the  vascular  system  cause  the  involvement  of  the  latter  to  assume 
a  very  important  role  in  the  processes  both  of  protection  and  of  repair.  Further, 
the  influence  of  the  nervous  system  is  also  a  factor  of  great  importance  in  con- 
nection with  these  processes. 

If  we  should  select  the  most  constant  and  characteristic  phenomenon  of  the 
reaction  to  injury  in  multicellular  organisms  it  would  be  found  to  lie  in  the 
assemblage  of  cells  of  the  leucocyte  type  at  the  site  of  injury.  These  cells, 
indeed,  may  be  regarded  as  analogous  to  imicellular  organisms,  and  they  pre- 
sent the  protective  functions  characteristic  of  the  latter.  The  difference  in 
reaction  to  injury  between  unicellular  and  multicellular  organisms  is  the  result 
simply  of  the  specialization  of  function  and  the  more  complex  mechanism  of 
the  latter.  It  becomes  clearly  evident,  therefore,  that  the  essential  jjrinciples 
imderlying  the  response  of  the  animal  organism  to  injur}^  are  the  same  for  all 
forms  of  animal  life  from  the  lowest  to  the  highest.  And  it  is  to  this  reaction  of 
the  animal  organism  to  injurious  agents  and  the  lesions  produced  by  them  that 
we  now,  in  accordance  with  the  majority  of  modern  pathologists,  apply  the 
term  inflammation. 


2.  Differences  of  Conception  of  the  Inflammatory  Process. 

The  earliest  conception  of  inflammation  {inflammatio,  phlogosis)  was  a  purely 
clinical  one.  At  the  beginning  of  the  Christian  era  the  term  was  applied  by 
Celsus  to  local  changes  in  the  superficial  portions  of  the  body  characterized  by 
redness  (rubor),  swelling  {tumor),  heat  (calor),  and  pain  (dolor).  Since  these 
phenomena  appeared  constantly  as  the  results  of  certain  injm-ies  and  irritants 
to  the  external  portions  of  the  body  Celsus  designated  them  as  the  four  cardi- 
nal symptoms  of  inflammation.  Later,  a  fifth  symptom  of  disturbed  fimction 
(functio  lasa)  was  added.  While  this  primitive  definition  ctlil  exercises  a  tradi- 
tionary influence,  the  term  inflammation  has  gradually  come  to  include  a  large 
number  of  pathological  conditions  of  the  internal  organs  believed  to  be  analo- 
gous to  the  inflammatory  process,  as  well  as  all  those  morbid  processes  which 
in  etiology  and  course  caimot  be  separated  from,  and  which  pass  insensibly  into, 
conditions  showing  the  classical  symptoms.  The  term,  therefore,  gradually 
came  to  be  applied  to  conditions  in  which  some  or  all  of  the  cardinal  signs  were 


INFLAMMATION.  73 

absent  or  could  not  be  recognized,  and  the  purely  clinical  significance  at  first 
attached  to  it  was  weakened  or  lost.  Such  a  usage  may  be  taken  as  an  indica- 
tion of  the  awakening  realization  that  all  the  processes  included  under  the  term 
were  in  essence  of  the  same  nature  and  significance.  And  that  this  latter  is  a 
fact  has  been  demonstrated  beyond  all  doubt  by  the  study  of  the  minute  changes 
in  the  organs  and  tissues  in  and  about  the  inflamed  area  and  by  the  results 
obtained  through  experimental  and  comparative  pathology. 

From  Boerhave,  who  regarded  inflammation  as  the  result  of  stasis,  to  Rokitan- 
sky,  who  emphasized  the  vascular  dilatation,  slowing  of  the  blood  stream,  and 
serous  exudation,  to  Virchow,  who  regarded  inflammation  as  an  overstimulation 
of  the  functional,  nutritive,  and  formative  irritability  of  the  cells,  and  finally  to 
Cohnheim,  who  first  studied  the  phenomena  of  inflammation  in  the  living 
animal  directly  under  the  microscope  and  was  thus  enabled  conclusively  to 
demonstrate  that  the  cardinal  changes  are  vascular  disturbances  leading  to 
emigration  of  the  white  cells,  serous  exudation,  and  diapedesis  of  red  cells,  there 
may  be  traced  a  constant  widening  of  the  field  covered  by  the  designation  in- 
flammation, so  that  the  term  came  to  be  applied  to  the  great  majority  of  patho- 
logical processes  in  the  body  without  reference  to  the  original  symptomatic  sig- 
nificance. But  even  Cohnheim  was  unable  to  see  anything  in  the  inflammatory 
process  of  service  to  the  body;  its  chief  significance  to  him  lay  in  the  primary 
lesion  of  the  blood-vessels  permitting  the  passage  of  the  blood  elements.  While 
giving  to  pathology  the  important  knowledge  of  the  vascular  alterations  occur- 
ring in  the  inflammatory  process,  Cohnheim  threw  no  light  upon  its  essential 
nature.  His  views,  however,  were  for  a  long  time  accepted  as  the  most  satis- 
factory interpretation  of  the  inflammatory  phenomena,  and  they  still  influence 
greatly  some  of  the  leading  pathologists  of  the  present  day. 

During  the  last  several  decades  efforts  have  been  constantly  made  to  ascer- 
tain the  common  feature  of  the  various  processes  classed  as  inflammatory,  with 
the  view  of  arriving  at  a  fundamental  conception  of  the  inflammatory  process. 
The  varied  etiology  and  the  very  different  clinical  and  histological  pictures  pre- 
sented by  different  inflammations  afforded  no  basis  for  a  fundamental  definition. 
In  the  effort  to  make  of  inflammation  both  a  clinical  and  a  pathological  entity 
the  term  itself  fell  somewhat  into  disrepute  with  both  clinicians  and  patholo- 
gists, and  it  was  even  proposed  by  some  (Thoma,  Andral,  and  others)  to  drop 
it  altogether. 

But  a  new  conception  of  the  process  was  slowly  evolving — one  which  would 
be  able  to  harmonize  all  facts,  remove  all  difficulties,  and  give  to  mflammation 
an  entity,  not  as  a  condition  or  state,  but  as  a  process  having  in  all  of  its  mani- 
fold manifestations  one  essential  unity,  viz.,  that  of  protective  and  reparative 
reaction  to  injury.  This  new  conception  may  be  said  to  have  had  its  origin  with 
the  discovery  of  karyokinetic  cell-division  and  the  demonstration  that  in  prac- 
tically all  inflammatory  lesions  cell  proliferation  occurs  to  a  greater  or  less  de- 


74  AMERICAN  PRACTICE  OF  SURGERY. 

gree.  At  first,  this  new  formation  of  cells  was  regarded  as  a  sequela  of  inflamma- 
tion rather  than  as  an  essential  part  of  the  process.  But  it  was  soon  discovered 
that  other  features  of  the  inflammatory  process  could  likewise  be  demonstrated 
to  be  protective  in  character. 

To  ]Metschnikoff  do  we  owe  the  knowledge  that  the  assemblage  of  wandering 
cells  at  the  point  of  injury  may  precede  and  be  independent  of  the  vascular 
changes,  and  that  this  phenomenon  constitutes  the  most  characteristic  and 
constant  factor  of  the  reaction  to  injury.  Regarding  this  collection  of  wandering 
cells  as  primarily  intended  for  the  exercise  o  f  their  function  as  phagocytes,  Met- 
schnikoff  formulated  a  new  conception  of  mflammation  as  a  reaction  of  phago-  ■ 
cytes  against  the  injurious  agent.  The  essential  and  fmidamental  element  of  in- 
flammation is,  then,  a  means  of  defence  for  the  animal  organism.  ^^Trile  the  new 
conception  of  inflanmration  as  adaptive,  protective,  and  reparative  owes  more 
to  Metschnikoff  than  to  any  other  modern  investigator,  yet  his  efforts  to  estab- 
lish phagocytosis  as  the  essential  element  of  the  process  must  be  regarded  as 
based  upon  a  too  narrow  conception.  That  phagocytosis  is  only  one  of  the  pro- 
tective functions  of  the  bod}'-cells  exercised  in  inflammation  was  clearly  recog- 
nized by  other  investigators,  and  the  lines  of  work  followed  in  opposition  to 
Metschnikoff's  views  have  served  to  give  a  still  firmer  and  broader  foimdation 
to  the  new  conception. 

The  demonstration  of  the  active  participation  of  the  blood-vessels  and  endo- 
theliimi  (Klebs,  Heidenhain,  and  others),  the  influence  of  the  nervous  system  (Sam- 
uel), the  part  played  by  chemotaxis  (Bordet,  Leber,  Buchner,  Gabritschewsky, 
and  others),  and  the  presence  in  the  blood  and  serum  of  antibacterial  bodies 
(alexins)  (Nuttall,  Buchner,  and  others)  served  fm-ther  to  establish  the  new  con- 
ception more  securely.  It  has  been  shown  also  that  leucocytes  contain  or  pro- 
duce bactericidal  substances  (Buchner,  Hankin,  Bordet,  Stokes  and  Wegefarth, 
Loewit,  and  others).  The  bactericidal  action  of  the  serum  in  inflammatory  proc- 
esses has  been  conclusively  demonstrated,  as  has  also  the  mechanical  protection 
afforded  by  the  cellular  infiltration,  fibrinovL?  exudate,  granulation-tissue,  etc. 
The  function  of  the  fluid  exudate  in  diluting  or  washing  away  injuiious  agents 
may  also  be  mentioned  as  one  of  the  protective  factors  of  minor  importance. 
Lastly,  but  constituting  one  of  the  most  important  factors  in  the  body's  defen- 
sive processes,  is  the  production  by  the  body-cells  of  antitoxins  whereby  injm-ious 
chemical  agents  are  neutralized  or  destroyed.  Ehrlich's  theory  serves  to  illu- 
minate the  processes  of  local  inflammation  as  well  as  of  general  infections  and 
intoxications. 

Summing  up,  then,  all  the  factors  of  the  inflammatory  process  and  viewing 
them  in  the  light  of  modern  research  we  see  that  in  all  anunals  and  in  response 
to  all  kinds  of  injury  they  are  essentially  the  same,  though  often  varying  in  pro- 
portion, and  that  their  imity  lies  in  a  constant  tendency  toward  protection  and 
repair.     Inflammation,  therefore,  as  defined  above,  can  be  regarded  only  as  a 


INFLAiniATION.       .  75 

frocess-cormpLex  essentially  adaptive,  protective,  and  reparative,  called  into  action 
by  a  primary  tissue  lesion. 

To  this  view  nearly  all  the  pathologists  of  the  present  clay  accede.  A  few 
examples  of  recent  definitions  may  be  given  here : 

Inflammation  is  the  series  of  changes  constituting  the  local  manifestation  of  the 
attempt  at  repair  of  actual  or  referred  injury  to  a  part,  or,  briefly,  as  the  local  attempt 
at  repair  of  actual  or  referred  injury. — Adajii. 

Inflammation  is  a  local  reaction,  often  beneficial,  of  the  hving  tissue  against  the 
uTitating  substance.  This  reaction  is  produced  chiefly  by  phagocytic  acti\'ity  of  the 
mesodermal  cells.  In  this  reaction  there  may,  however,  participate  not  only  changes 
of  the  vascular  system,  but  also  the  chemic  action  of  the  blood  plasma  and  tissue 
fluids  in  liquefying  and  dissolving  the  irritant  agent. — PoD-m.-ssozKi. 

Inflammation  is  the  reaction  of  the  tissues  to  local  injiuries  calhng  forth  protec- 
tive measures:  an  imperfect  pathologic  adaptation,  often  leacUng  to  consequences 
that  are  dangerous  per  se  and  may  defeat  its  piurpose. — Hektoen. 

On  the  whole  the  processes  involved  in  inflammation  are  conservative,  and, 
■within  the  limitations  which  may  be  set  by  the  varied  and  changing  conditions  of 
injury,  tend  to  maintain  the  welfare  and  sustain  the  fife  of  the  indi\'idual. — Dela- 
FiELD  and  Peudden. 

The  reaction  of  the  organism  against  injurious  agents.  .  .  .  Local  inflammation 
may  be  regarded  as  an  increased  tissue  function  which  is  also  active  under  normal 
conditions  but  of  so  slight  a  degree  as  not  to  be  perceived. — Ribbert. 

Only  a  few  pathologists,  among  these  Ziegler,  still  emphasize  the  tissue 
lesion,  particularly  the  vascular  alteration,  as  the  most  essential  feature  of  the 
inflammatory  process.  But  among  surgical  writers  we  find  a  small  number, 
who,  following  Hueter's  dicta,  assert  that  the  term  inflammation  should  be  ap- 
plied only  to  the  processes  caused  by  pyogenic  micro-organisms;  that  is,  to 
suppiu-ative  processes.  This  confusion  of  inflammation  and  pyogenesis  is  illogi- 
cal and  unfortimate.  There  is  no  etiological  entity  to  which  the  application  of 
the  term  inflammation  can  be  restricted.  Physical,  chemical,  and  thermal  agents 
can  produce  precisely  the  same  changes  as  those  seen  in  local  infections.  On 
the  other  hand,  infection  may  occur  without  inflammation.  The  fact  that 
purulent  inflammations  are  the  most  common  and  important  forms  of  the  proc- 
ess falling  within  the  province  of  practical  surgery  gives  no  warrant  for  the 
usurpation  by  this  branch  of  medicine  of  the  term  inflammation  for  one  particu- 
lar manifestation  of  the  inflammatory  process.  The  term  has  been  too  long 
applied  to  various  other  processes  of  essentially  the  same  nature  and  significance 
to  permit  of  such  a  narrowing  of  its  meaning.  If  the  phenomena  of  the  local 
reaction  of  the  body  to  injurious  agents  are  in  essence  the  same,  no  matter  what 
the  etiological  agent  may  be,  the  term  inflammation  must  include  them  all. 
That  they  are  the  same,  in  all  essential  respects,  will  be  shown  in  the  following 
paragraphs. 


76  AMERICAN  PRACTICE  OF  SURGERY. 

3.  The  Reaction  of  the  Tissues  to  Injuey. 

Injury  to  Non- vascular  Tissues.— The  cornea  offers  itself  as  suitable  mate- 
rial for  the  study  of  the  effects  of  injury  upon  non-vascular  tissues.  According 
to  Senftleben  and  others,  if  the  centre  of  the  rabbit's  cornea  be  touched  with  a 
strong  solution  of  zinc  choloride  without  causing  an  actual  break  in  its  continu- 
ity, there  is  a  necrosis  of  the  corneal  cells  at  the  point  of  application,  with  the 
development  of  an  encircling  zone  in  Avhich  the  corneal  cells  are  enlarged,  granu- 
lar, and  tumefied.  There  is  apparently  no  increase  of  wandering  cells  and  the 
necrosed  cells  are  replaced  through  the  multiplication  of  the  neighboring  hyper- 
trophic cells.  The  two  essential  features  here  are  cell' necrosis  and  cell  division; 
and  such  a  process  must  be  regarded  as  the  simplest  form  of  an  inflammation.  It 
is  doubtful,  however,  if  such  a  simple  form  actually  occurs  under  such  condi- 
tions. It  is  almost  impossible  to  repeat  Senftleben's  results;  in  the  great  ma- 
jority of  cases,  if  not  in  all,  the  slightest  perceptible  injury  to  the  cornea  causes 
an  increase  in  the  number  of  wandering  cells  in  or  about  the  damaged  area. 
As  the  neighboring  vessels  of  the  conjunctiva  may  show  no  perceptible  changes, 
it  is  most  probable  that  the  wandering  cells  come  to  the  damaged  area  out  of 
the  lymph  spaces  of  the  surrounding  tissue  (see  Fig.  28). 

If  a  simple  cut  be  made  into  the  cornea,  either  with  or  without  previous 
cauterization,  practically  the  same  changes  are  seen.     There  occurs  within  a 
short  time  a   collection   of  leucocytes   in   and 
■^'^•'^^'^Zj^    ^'  -aT"    -=■  '"■''      about  the  point  of  incision.     At  first,  these  are 
apparently    attracted    from    the    surrounding 
tissue,  as   the  blood-vessels  of  the  conjunctiva 
may  show  no  changes.     Cell  division  takes  place 
and  repair  is  effected.     The  inflammatory  proc- 
ess consists,   then,   essentially   of    cell   injury, 
positive    chemotaxis,    and    cell     proliferation. 
When  the  degree  of  the  trauma  is  greater  (re- 
^'""'"'7"         .  --         -s.-^-"^;       peatcd  trauma   or   cauterization,  repeated  ap- 
'*£_^_ia^A^"   ■■^-    ""     ■'''Slit/       plication   of   toxin),  the  neighboring  vessels  of 
Fig.  28.— Inflamed  Cornea.    Hy-     the  Conjunctiva  bccome  iiivolved,  as  shown  by 
pertrophy  of  corneal  cells ;  assemblage     ^j^^- j,  dHatation,  increased  number  of  leucocytes, 

of  leucocytes.      {After  Ribbcrt.)  ^         ' 

and  leucocyte  emigration,  as  well  as  by  serous  ex- 
udation. The  leucocytes  mass  themselves  in  greater  numbers  about  and  in  the 
injured  area.  The  number  may  become  so  great  that  the  tissue  presents  the  ap- 
pearance of  a  purulent  infiltration.  Licjuef action  necrosis  may  take  place  (re- 
peated application  of  chemicals  or  toxins),  and  the  histological  picture  produced 
may  l^e  exactly  similar  to  that  following  the  growth  of  pyogenic  micro-organisms. 
If  pyogenic  bacteria  are  injected  into  the  centre  of  the  cornea  and  multi- 
plication of  the  organisms  follows,  there  is  first  seen  around  the  growing  colony 


i 


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;;!g^_--'-'5•■     ^'.':- 

,  _     ■^''  'hi"' 

P^      .-.,>y®^ 

'^        ®  4EK    -.w. 

.^  V-  "Kr; 

V^-.-'ISl^-c.- 

-.^-«S>-'  ^'' 

^*-:^.    ^- 

*'        .WSSs: 

INFLAMMATION. 


77 


a  zone  of  degeneration  and  necrosis  of  the  corneal  cells.  Within  a  short  time 
leucocytes  collect  about  the  damaged  area,  coming  first  from  the  corneal  tissues 
and  later  from  the  blood-vessels  at  the  periphery  of  the  cornea.  These  vessels 
are  found  to  be  dilated  and  containing  an  increased  number  of  leucocytes. 
They  present  also  evidences  of  serous  exudation  and  emigration  of  the  leuco- 
cytes. That  the  leucocytes  come  chiefly  from  the  vessels  is  shown  at  a  certain 
stage  by  their  greater  number  at  the  periphery  of  the  cornea  and  their  gradual 
approach  toward  the  area  of  injury.  Finally,  large  numbers  of  leucocytes  may 
be  collected  in  the  lymph  spaces  about  the  tissue  lesion.  If  the  bacteria  intro- 
duced were  of  a  low  virulence,  or  if  the  body's  resistance  is  sufficient  to  inhibit 
the  growth  of  the  colony  or  to  kill  it,  proliferation  begins  and  repair  is  effected. 
The  inflammatory  process  under  such  circumstances  in  no  way  differs  from  that 
produced  by  other  agents. 

If  the  micro-organisms  injected  are  virulent  and  continue  to  develop,  the 


Fig.  28,  A. — Corneal  Suppuration,  a,  Limbus  corneiE  with  hyperaemia  of  ciliary  vessels  and  purulent 
infiltration;  6,  remains  of  epithelium;  c,  purulent  infiltration  of  cornea;  d,  necrosis;  e,  pus;  /,  Descemet's 
membrane;   g,  endothelium  of  anterior  chamber.     {After  Weichselbaum.) 

area  of  necrosis  and  degeneration  widens,  more  leucocytes  come  into  the  dam- 
aged area,  the  lymph  spaces  contain  more  fluid,  and  the  peripheral  vessels 
show  a  more  marked  reaction.  Many  of  the  leucocytes  are  seen  to  be  acting 
as  phagocytes,  having  taken  up  large  numbers  of  the  invading  organisms.  After 
a  time  the  leucocytes  massed  in  the  central  portion  of  the  necrotic  area  undergo 
degeneration,  and  a  liquefaction  of  the  infiltrated  necrotic  centre  follows,  lead- 
ing to  the  formation  of  an  ulcer  (see  Fig.  28,  A).     The  virulence  of  the  infective 


78  --LMERICAX   PRACTICE   OF  SLTIGERY. 

agent  may  now  be  weakened,  or  the  latter  may  be  restrained  from  further 
groTvth  by  the  leucocyte  barrier.  Proliferation  of  the  neighboring  corneal  cells 
may  take  place,,  the  dead  tissue  and  leucocytes  bemg  either  cast  off  or  organized, 
and  the  ulcer  finally  becomes  completely  healed.  In  the  process  of  repau-  new 
blood-vessels  may  grow  mto  the  cornea  from  the  blood-vessels  of  the  sm-rounding 
tissues,  and  the  pre^-iously  avascular  tissue  then  becomes  vascularized.  Should 
the  organism  be  unable  to  overcome  the  vu-ulenee  of  the  infective  agent,  the  area 
of  necrosis  and  degeneration  increases  and  the  inflammatory  process  extends. 

Injury  to  Vascular  Tissues.— The  skin  or  mesentery  of  experimental  ani- 
mals may  be  utilized  for  the  demonstration  of  the  changes  set  up  by  injury  to 
vascular  tissues.  If  the  slightest  possible  injury  that  can  be  recognized  be  pro- 
duced in  such  tissues  by  means  of  heat,  chemical  action,  or  aseptic  incision, 
practically  identical  changes,  varymg  only  in  degree,  will  be  fomid  at  the  point 
of  injury.  The  sunple  aseptic  incision  may  be  taken  as  an  example.  The  solu- 
tion of  contmuity  of  the  incised  part  leads  at  once  to  a  necrosis  or  degeneration 
of  the  cells  along  the  line  of  incision.  The  edges  of  the  wotmd  are  almost  im- 
mediately glued  together  by  serum  or  blood  clot,  and  there  is  a  slight  serous 
infiltration  of  the  tissue  bordering  upon  the  incision.  The  tissue  cells  in  the 
immediate  neighborhood  of  the  cut  enlarge  and  send  out  processes  into  the 
exudate,  binding  the  sides  of  the  wound  together.  Protoplasmic  bridges  maj^ 
thus  be  formed  across  the  wound.  At  the  same  time  the  neighboring  capillaries 
show  slight  or  moderate  dilatation,  and  there  is  a  slight  increase  of  wandering 
cells.  Later,  cell  proliferation  with  a  new  formation  of  capillaries  takes  place 
and  the  tissue  continuitj-  is  again  restored.  In  the  epidermis  the  reaction  to 
the  injur}-  is  shown  simply  by  a  new  formation  of  epithelial  cells.  There  action 
to  slight  injm}-  in  vascular  tissues  is  characterized,  therefore,  by  slight  vascular 
changes,  emigration  of  leucocytes,  and  exudation,  the  chief  factor  of  the  reac- 
tion being  progressive  changes  (hypertrophy  and  proliferation)  of  the  tissue 
cells.  There  is,  then,  no  essential  difference  in  the  reaction  to  slight  mjury  in 
avascular  and  vascular  tissues. 

If  the  degree  of  injur\'  be  more  marked,  so  that  the  tissue  lesion  (degenera- 
tion and  necrosis)  is  more  extensive,  there  is  a  more  pronoimced  and  rapid 
reaction  on  the  part  of  the  blood-vessels.  These  show  a  marked  dilatation,  with 
slowing  of  the  blood  stream,  marginal  disposition  of  the  leucoc3'tes,  increased 
formation  of  hmiph,  and  emigration  of  leucocytes  from  the  vessels.  Red  blood 
cells  maj-  also  escape.  The  leucocytes  collect  in  the  tissue  spaces  in  or  about 
the  injured  area  (see  Fig.  29).  "^lien  the  process  is  on  the  superficial  portions 
of  the  body  the  classical  sjmiptoms  maj-  be  present.  According  to  the  nattrre  of 
the  irritant,  its  virulence,  and  the  resisting  powers  of  the  organism,  the  inflam- 
matory process  may  continue  to  extend  or  cell  proliferation  may  begin,  the 
exudate  disappears,  the  vessels  resume  their  normal  condition,  and  all  traces 
of  the  injury  and  the  reaction  pass  away. 


INFLAMMATION.  79 

Should  the  injurious  agent  be  one  capable  of  unlimited  growth  and  continu- 
ous injury  to  the  bodj^  tissues,  as  is  the  case  with  virulent  pathogenic  organ- 
isms, the  pus  cocci  in  particular,  the  tissue  lesion  is  more  severe  and  assumes  a 
progressive  character,  while  the  inflammatory  reaction  is  proportionately  more 
marked.  When  the  focus  of  irritation  is  situated  in  the  superficial  parts  of  the 
body  the  classical  symptoms  are  usually  clearly  defined.  On  microscopical 
examination  precisely  the  same  essential  changes  are  found  as  in  the  non- 
infective  inflammations,  the  only  difference  being  one  of  intensity  and  adapta- 
tion to  the  different  character  of  the  injurious  agent.  At  the  point  of  a  pyo- 
genic infection  there  is  produced  by  the  growing  colony  of  bacteria  a  tissue 
degeneration  or  necrosis.  About  this  lesion  there  is  a  rapid  and  marked  vas- 
cular reaction.  Within  a  few  hours  usually  the  vessels  are  found  to  be  markedly 
congested,  packed  with  red  blood  cells,  and  showing  a  marginal  disposition  of 


Fig.  29. — Inflamed  Human  Mesentery  (osmic-acid  preparation),  a,  Normal  trabecula:  b,  normal 
epithelium  (endothelium);  c,  small  artery;  d,  vein  witli  leucocytes  arranged  peripherally;  e,  white 
blood  cells,  which  have  emigrated  or  are  emigrating;  /,  desquamating  endothelium;  fi,  multinuclear 
cells;    g,  extravasated  red  blood  cells.      X  ISO.      {After  Ziegler.) 

the  leucocytes,  which  are  greatly  increased  in  number.  In  the  tissues  the 
number  of  wandering  cells  is  greatly  increased.  The  mononuclear  forms  are 
very  numerous  and  often  predominate.  Both  leucocytes  and  tissue  cells  acting 
as  phagocytes  and  containing  numbers  of  the  bacteria  may  be  found.  As  a 
rule,  the  leucocytes  in  the  immediate  neighborhood  of  the  growing  colony 
are  multi-  or  polymorphonuclear,  while  in  the  outer  zone  of  the  infiltration  the 
mononuclear  forms  prevail. 

As  the  process  advances,  the  damaged  area  becomes  densely  infiltrated  with 
leucocytes,  the  dead  tissue  elements  undergo  liquefaction,  while  the  leucocytes 
in  the  area  of  softening  show  signs  of  degeneration.     The  process  has  now  reached 


80  AMERICAN  PRACTICE  OF  SURGERY. 

the  stage  known  as  suppuratwn,  and  there  is  formed  an  abscess  more  or  less 
sharply  defined  from  the  surrounding  tissues  (see  Fig.  29,  A) .  If  on  a  surface,  the 
suppuration  leads  to  a  superficial  loss  of  substance— an  ulcer.  The  mass  of 
leucocytes  occupying  the  central  necrotic  area  constitutes  pus.  In  this  pus  the 
great  majority  of  the  leucocytes  are  found  to  be  phagocytes— that  is,  they  con- 
tain numbers  of  the  infective  organism.  About  the  border  of  the  pus  area  the 
tissues  are  swollen,  more  or  less  infiltrated,  the  blood-vessels  congested,  and 
there  is  more  or  less  hemorrhage.  At  this  stage  no  evidences  of  cell  prolifera- 
tion can  usually  be  found.  If  the  infective  agent  has  great  virulence,  the  proc- 
ess may  continue  to  extend  indefinitely  with  a  repetition  of  the  same  phenom- 
ena, and  finally  become  generalized,  or  the  organism  may  succumb.  If  the 
virulence  is  overcome  and  the  colony  of  bacteria  dies  out  or  ceases  to  reproduce, 

.    -;     ■.•:■--  :- -_   -:   "■:■:-'-  '     v^       '       p^- 

Fig.  29,  A. — Small  Abscess  in  Heart  Muscle.     Colony  of  pyogenic  cocci  in  centre  of  necrotic  area,  which 
is  surrounded  by  a  zone  of  leucocyte  infiltration.      {After  Ribbert.) 

cell  division  begins  about  the  border  of  the  abscess,  new  capillaries  extend  into 
it,  and  the  area  is  gradually  replaced  by  new  tissue. 

The  same  picture  of  suppuration  may  be  produced  by  the  injection,  into  the 
tissues,  of  certain  chemical  irritants,  such  as  turpentine,  mercury,  petroleum, 
creolin,  bacterial  toxins,  etc.  Inasmuch  as  under  such  circumstances  there  is 
no  continuous  production  of  irritating  substances,  as  in  the  case  of  bacterial 
infection,  the  purulent  reaction  thus  produced  lasts  for  a  shorter  time,  cell  pro- 
liferation begins  more  quickly,  and  healing  is  attained  in  less  time.  Continuous 
injections,  however,  will  cause  a  progressive  purulent  process,  not  to  be  distin- 
guished in  any  way  from  that  due  to  bacterial  infections,  in  so  far  as  the  local 
phenomena  are  concerned. 

In  the  case  of  certain  injurious  agents  the  inflammatory  reaction  is  charac- 
terized by  serous  exudation  rather  than  by  leucocytic.  Others  still  are  charac- 
terized by  the  production  of  a  fibrinous  exudate.  The  same  agent  may  at  one 
time  produce  a  reaction  characterized  by  suppuration,  at  another  time  one 
characterized  by  serous  exudation,  and  under  other  conditions  it  may  give  rise 
to  an  exudate  consisting  chiefly  of  fibrin.  These  variations  in  the  inflammatory 
reaction  are  especially  characteristic  of  those  inflammations  which  are  due  to 
infections.  The  factors  modifying  the  nature  of  the  reaction  are  many:  the 
nature  of  the  injurious  agent,  the  location  and  character   of   the  injury,   the 


INFLAMMATION.  81 

degree  of  intensity,  the  general  and  local  conditions  of  the  organism,  etc.,  all  of 
which  serve  to  give  to  the  inflammatory  reaction  a  varied  clinical  and  patho- 
logical picture. 

Nevertheless,  as  we  have  seen  above,  there  is  a  unity  in  the  reaction  to  in- 
jury which  makes  of  the  inflammatory  process  a  distinct  entity,  no  matter 
what  the  nature  of  the  injurious  agent  or  the  conditions  under  which  it  acts. 
Whether  traumatic,  thermal,  chemical,  or  infective  in  etiology,  or  formative, 
serous,  purulent,  or  fibrinous  in  character,  the  process  has  the  entity  of  adapta- 
tion, protection,  and  repair  against  injury.  As  Ribbert  and  others  have  pointed 
out,  inflammation  may  be  conceived  of  as  a  body  function — the  function  of 
protection,  and  comparable  to  the  other  body  functions.  Cell  proliferation, 
chemotaxis,  emigration  of  leucocytes,  phagocytosis,  the  production  of  anti- 
bodies, etc.,:  are  probably  always  taking  place  in  the  body  to  some  extent,  but 
unnoticed.  Only  when  the  demand  made  upon  this  function  is  so  great  as  to 
become  locally  prominent  does  it  become  manifested  in  the  form  of  an  inflam- 
.mation.  If  it  be  urged  against  this  view  that  the  inflammatory  process  often 
in  itself  is  a  source  of  danger  to  the  organism,  the  same  might  be  applied  to 
other  functions — for  instance,  the  digestive,  the  products  of  digestion  often 
becoming  factors  in  auto-intoxications.  Viewed  broadly,  inflammation  is  to  be 
regarded  as  a  phylogenetic  evolution,  developing  as  have  all  the  other  functions 
of  the  organism. 

4.  Etiology  of  Inflammation. 

The  inflammatory  process  has  no  etiological  entity.  The  causes  of  inflam- 
mation are  not  specific.  Any  injurious  agent  may  produce  inflammation,  pro- 
vided its  action  is  not  so  severe  as  to  kill  the  organism  or  the  tissues  en  masse 
or  to  inhibit  the  function  of  protection  and  repair.  Extrinsic  agents — such  as 
mechanical,  thermal,  chemical,  electrical,  radio-active,  infective,  etc. — are 
among  the  most  common  causes  of  inflammation.  In  surgical  practice  it  is 
chiefly  with  these  extrinsic  causes  that  the  surgeon  has  to  deal.  But  injurious 
agents  capable  of  exciting  inflammation  may  be  produced  within  the  body  as 
the  result  of  disturbed  metabolism,  disordered  function,  etc.  The  antemic 
necrosis  of  tissue  areas  due  to  local  obstruction  of  the  blood-vessels  excites  also 
an  inflammatory  reaction  in  the  neighboring  living  tissues. 

In  the  great  majority  of  cases  the  inflammatory  reaction  is  probably  toxic 
in  origin.  The  irritant  poison  is  chiefly,  as  far  as  surgery  is  concerned,  bacterial. 
In  general  medical  work  inflammatory  processes  due  to  auto-intoxications  oc- 
cupy also  a  prominent  position. 

The  agents  causing  inflammation  may  act  upon  the  body  from  without 
(edogenous  inf.ammation)  or  through  the  lymph  (lymphogenous)  or  the  blood 
(hcematogenous) .  When  the  avenue -of  entrance  of  the  injurious  agent  (bacteria) 
is  not  known,  the  inflammation  is  styled  cryptogenic. 


82 


A]^IERICAN  PRACTICE  OF  SURGERY. 


The  inflammatory  process  may  spread  by  direct  extension  (inflammatioji  hy 
continuity),  or  the  injurious  agent  may  be  transported  through  the  lympli  or 
blood  stream  to  other  parts  of  the  body,  there  to  excite  new  inflammatory  foci 
{metastatic  inflammation).  Through  the  excretion  of  poisonous  substances  the 
excretory  organs  may  become  the  seat  of  inflammatory  processes  {excretory 
inflammation). 

The  action  of  the  harmful  agent  may  be  very  transitory  or  it  may  be  pro- 
longed through  some  period  of  time.  Particularly  is  this  the  case  with  infective 
agents.  Through  the  continuous  new  formation  of  poisonous  substances  by  the 
colony  of  living  parasites,  an  inflammatory  reaction  may  be  kept  up  almost 
indefinitely  imtil  the  organism  finally  conquers  or  succumbs.  The  action  of  the 
inflammatory  agent  may  be  so  slight  as  to  produce  a  lesion  that  is  clinically 
unrecognizable,  and  even  on  microscopical  examination  the  evidences  of  damage 
to  the  tissue  are  with  difficulty  made  out.  At  other  times  the  action  is  so  intense 
that  extensive  lesions  easily  seen  by  the  unaided  eye  are  produced. 

Usually  the  inflammatory  reaction  quickly  follows  the  injury,  the  interval 
of  time  varying  from  a  few  hours  to  a  few  days ;  but  in  some  instances  the 
reaction  is  long  delayed.  The  character  of  the  exciting  cause,  its  virulence,  the 
conditions  of  nutrition  about  the  damaged  area,  the  influence  of  the  nervous 
system,  etc.,  are  probably  the  chief  factors  causing  a  delayed  reaction.  Some 
agents  may  inhibit  the  protective  function  or  even  cause  destruction  of  some 
of  the  elements  therein  concerned.  Roentgen  rays,  for  example,  will  cause  a 
disintegration  of  the  leucocytes  in  the  irradiated  area  and  also  inhibit  cell  pro- 
liferation. These  facts  may  explain  in  part  the  long- delayed  inflammatory 
reaction  seen  after  repeated  exposure  to  the  rays. 


5.  The  Factors  Coxcerned  in  the  Infl.a.mm.\tory  Process. 

In  the  surveyal  of  the  course  of  inflammatory  processes  in  general,  the  vari- 
ous associated  phenomena  are  found  to  fall  into  several  more  or  less  well-defined 
The  Factoks  Concerned  in  the  Inflammatory  Process. 


1.  Effects  of  Injurious 

2.  REACTION. 

3.  Resolution. 

Tissue-Lesion. 

Protective  ana  Defensive. 

Reparative. 

a.  Disturbance  of   cell 

Chemotaxis. 

Vascular  disturb- 

Phagocytosis. 

a.  Cell-prolifera- 

relation. 

Leucocytosis. 

ances. 

Chemical  protec- 

tion. 

h.  Solution  of  continu- 

Emigration of 

a.  Congestion. 

tion. 

b.  Regeneration. 

ity. 

■white  cells. 

b.  Stasis. 

a.  Antibacterial. 

c.   Organization. 

c.  Tissue  degenerations. 

c.   Leucocytosis. 

b.  Antitoxic. 

d.  Cicatrization. 

d.  Necrosis. 

d.  Marginal    dis- 

position. 

e.  Emigration. 

/.    Serous  exuda- 
tion. 
q.  Diapedesis. 
h.  Thrombosis. 

Mechanical. 

Dilu(»nt. 

Irrigant. 

INFLAMMATION.  83 

groups,  the  first  of  these  being  the  immediate  results  of  the  harmful  agent,  the 
second  consisting  of  factors  essentially  protective  and  defensive,  while  the  third 
group  is  made  up  of  the  formative  and  reparative  factors.  The  general  process 
of  the  reaction  to  injury  having  been  sketched  above,  it  may  now  be  profitable 
to  consider  more  in  detail  the  most  important  factors  of  these  groups. 

Tissue-Lesion. — Although  the  primary  tissue-lesion  is  the  cause  and  not  a 
part  of  the  inflammatory  reaction,  it  is  difficult  practically  to  separate  it  from 
the  phenomena  which  are  immediately  dependent  upon  it,  and  it  is,  therefore, 
usually  included  in  a  general  survey  of  the  process  of  inflammation.  Moreover, 
from  the  clinical  side  the  changes  occurring  in  the  tissues,  either  primarily  as 
the  direct  result  of  the  action  of  the  etiological  agent  or  as  secondary  to  the 
inflammatory  process  itself,  are  of  the  greatest  practical  importance.  The  pri- 
mary tissue  lesion  varies  with  the  nature  of  the  etiological  agent,  the  intensity 
of  its  action,  the  location  of  the  injury,  the  condition  of  the  tissues,  the  general 
state  of  the  organism,  etc.  At  times  it  is  so  slight  as  not  to  be  recognizable 
either  with  the  naked  eye  or  microscopically;  at  other  times  so  severe  or  ex- 
tensive as  to  be  recognized  easily  macroscopically,  and  clinically  to  attract  the 
chief  attention.  This  is  particularly  the  case  when  the  injury  affects  a  large 
portion  of  the  tissues,  as  in  the  case  of  extensive  burns,  corrosions,  freezing,  or 
severe  and  widespread  infections.  In  the  case  of  bacterial  infections  the  tissue 
lesion  may  assume  a  progressive  character,  involving  large  areas  by  direct 
extension. 

The  primary  tissue  lesion  may  be  simply  a  disturbance  of  cell  relationship 
or  a  solution  of  continuity,  or  it  may  show  itself  in  the  form  of  any  one  of  the 
varieties  of  tissue  degenerations  or  necrosis.  The  acute  parenchymatous  degen- 
erations, cloudy  swelling,  hydropic  degeneration,  fatty  degeneration,  mucoid 
degeneration,  etc.,  and  the  various  forms  of  necrosis,  simple,  coagulation,  lique- 
faction, and  gangrenous,  are  the  most  common  tissue  lesions  exciting  the  in- 
flammatory reaction.  While  in  some  inflammations  the  tissue  lesion  may  be 
overshadowed  by  the  phenomena  of  the  reaction,  in  others  it  occupies  the  most 
prominent  position  both  clinically  and  microscopically. 

In  the  great  majority  of  cases  the  tissue  lesion  involves  the  blood-vessels  in 
or  about  the  site  of  injury,  but,  as  we  have  seen,  such  vascular  changes  are  not 
necessarily  a  part  of  the  inflammatory  reaction — as,  for  example,  in  the  corneal 
change  following  slight  injury.  Inasmuch  as  the  vascular  changes  may  take 
place  at  a  distance  from  the  actual  seat  of  injury,  the  participation  of  the  ves- 
sels in  the  reaction  must  be  explained,  in  such  cases  at  least,  upon  other  grounds 
than  that  of  a  direct  injury  to  the  vascular  walls.  There  is  good  reason  for 
believing  that  the  walls  of  the  blood-vessels  play  chiefly  an  active  part  in  the 
inflammatory  process,  and  not  merely  a  passive  one  due  to  injury. 

Secondary  injury  to  the  tissues  is  often  added  to  the  primary  lesion  as  the 
result  of  the  disturbances  of   circulation  and  nutrition  and  the  collection  of 


84  AMERIC.l^'   PRACTICE   OF   SURGERY. 

exudates  either  in  the  tissue  spaces  or  hi  the  body  cavities.  To  this  secondary 
damage  the  inflammatory  process  often  owes  its  clmical  unportance.  Moreover, 
the  dead  and  dymg  tissue  acts  as  a  further  source  of  mjury  to  the  surrounding 
healthy  tissue,  in  that  it  may  give  rise  to  chemical  products  which  are  uritant, 
and  so  extend  the  zone  of  damage.  This  is  most  likely  to  occur  in  the  early 
stages  of  necrosis;  later,  the  dead  tissue  becomes  chemically  indifferent  and  acts 
simply  as  a  foreign  body. 

The  Protective  Factors.  Che77wtaxis.—As  sho-wn  above,  the  chief  phe- 
nomena of  the  reaction  in  the  simplest  forms  of  inflammation  are  the  collection 
of  waudermg  cells  at  the  site  of  iujmy  and  the  proliferation  of  the  tissue  cells. 
This  assemblage  of  amceboid  cells  about  the  tissue  lesion  and  the  injurious 
agent  precedes  the  vascular  changes,  if  the  process  be  viewed  from  the  stand- 
point of  its  evolution.  The  attractive  force  exerted  upon  the  amoeboid  cells  is 
known  as  positive  cliemotaxis.  It  lies  m  diffusible  substances  produced  in  the 
mjm-ed  area,  through  altered  nutrition,  the  death  of  the  tissue  cells,  or  by  bac- 
teria. Such  substances  attract  the  amoeboid  cells  and  cause  their  assemblage 
at  the  site  of  injiu-y.  Negative  chemotaxis  may  also  occur,  but  positive  chemo- 
taxis,  although  varying  in  degree,  is  practically  the  rule  in  the  inflammatory 
reaction.  Particularly  hi  the  case  of  mfective  inflammations  is  positive  chemo- 
taxis marked,  the  great  majority  of  pathogenic  micro-organisms  producmg  sub- 
stances causing  the  amoeboid  cells  of  the  body  to  move  toward  the  bacteria. 
Chemotactic  influences  may  also  be  exerted  upon  the  white  cells  while  still  in 
the  blood-vessels,  and  in  part  at  least  may  accomit  for  their  occurrence  in 
greater  numbers  in  the  vessels  of  the  damaged  area  as  well  as  for  their  eniigra- 
•tion.  Such  influences  also  direct  the  movements  of  the  white  cells  after  they 
have  passed  out  of  the  vessels.  Ordinarily  the  leucocytes  leaving  the  vessels 
wander  in  the  direction  of  the  Ij-mph  stream.  In  the  case  of  tissue  injury  they 
wander  toward  the  site  of  the  lesion  and  the  injurious  agent.  About  the  latter 
they  collect  in  masses  and  remain  in  its  miniediate  ^acinity. 

Chemotaxis  brings  the  amoeboid  cells  to  the  point  where  their  phagocytic 
function  may  be  used  to  some  avail.  Not  only  upon  the  leucocj^tes  and  hTnpli- 
ocytes  are  such  influences  exerted,  but  also  upon  the  endothelial  cells  of  the 
vessel  wall  and  upon  the  formative  cells  arismg  through  the  proliferation  of  the 
fixed  cormective-tissue  cells.  T^Tiether  regarded  as  a  purely  accidental  phenom- 
enon or  as  an  attribute  of  the  injurious  agent  and  in  itself  ultimately  injurious, 
the  fact  remains  that  it  becomes  a  force  aiding  in  the  defence  and  protection  of 
the  body. 

Vascular  Changes. — ^As.  the  vast  majority  of  inflammatory  processes  occur 
in  vascular  tissues,  the  involvement  of  the  blood-vessels  plaj's  a  very  prominent 
role,  both  clinicalh'  and  pathologically.  The  first  noticeable  feature  of  the 
vascular  involvement  is  an  active  hypersemia,  the  arteries  being  dilated  and  the 
rate  of  the  blood  current  increased.     In  a  very  short  time,  however,  there  is  a 


INFLAMMATION.  85 

marked  slowing  of  the  blood  stream,  while  the  hypera?mia  remains  or  increases, 
the  capillaries  and  veins  becoming  greatly  dilated.  The  rate  of  the  blood  flow 
may  be  still  further  diminished  and  very  irregular.  In  portions  of  the  dam- 
aged area  a  condition  of  stasis  may  exist.  Thrombi  may  be  formed  in  the  veins. 
In  the  capillaries  about  the  irritant  (usually  when  infective)  there  are  some- 
times formed  masses  made  up  of  agglutinated  red  blood  cells  {agglutination 
thrombi). 

From  the  very  beginning  of  the  reaction  the  leucocytes  increase  in  numbers 
in  the  vessels  of  the  area,  and  as  the  blood  stream  becomes  slowed  their  number 
is  augmented  until  a  condition  of  a  more  or  less  marked  local  leucocytosis  exists. 
At  the  same  time  the  viscosity  of  the  white  cells  appears  to  be  increased,  since 
they  collect  in  numbers  along  the  vessel  wall,  where  they  remain  adherent  or 
move  along  but  very  slowly  (marginal  disposition  of  the  leucocytes). 

The  leucocytes  adherent  to  the  vessel  walls  now  begin  to  pass  out  in  num- 
bers {emigration  of  the  leucocytes).  This  process  is  accomplished  by  the  protru- 
sion of  a  cell  process  (pseudopodium)  through  the  intercellular  substance  be- 
tween the  endothelial  cells.  The  cell  protoplasm  follows  or  "flows"  after, 
mitil  finally  the  entire  cell  has  passed  outside.  Soon  numbers  of  leucocytes 
collect  outside  the  vessel  and  pass  thence  to  the  site  of  the  injury  or  the  in- 
jurious agent.  Through  the  openings  in  the  intercellular  cement  substance 
produced  by  the  passage  of  the  leucocytes  the  red  blood  cells  may  passively 
escape  {diapedesis) .  Hemorrhage  per  rhexin  may  also  occur  as  a  part  of  the 
inflammatory  process,  the  rupture  of  the  vessel  being  due  either  to  extreme 
dilatation  or  to  its  direct  involvement  in  the  tissue  lesion. 

At  the  same  time  there  is  an  increased  formation  of  lymph,  the  fluid  col- 
lecting in  the  tissue  spaces  as  an  inflammatory  adema  or  passing  out  upon  a 
free  surface  as  an  inflammatory  exudate.  From  the  normal  lymph  and  blood 
plasma  the  inflammatory  exudate  differs  in  its  albumin  content,  its  frequently 
high  fibrinogen  content,  as  well  as  by  differences  in  the  amomit  of  salts  con- 
tained. Emigration  and  exudation  do  not  always  go  hand-in-hand.  Some 
inflammatory  processes  are  characterized  by  a  fluid  exudation,  others  by  a 
cellular.  The  passage  of  the  fluid  cannot,  therefore,  depend  wholly  upon  the 
spaces  left  after  the  emigration  of  the  leucocytes.  Further,  the  difference  in 
composition  of  the  exudate  and  the  blood  plasma  must  also  be  taken  as  evi- 
dence of  a  different  mode  of  origin.  The  chemical  composition  of  the  exudate 
also  varies  in  different  parts  of  the  body. 

The  significance  of  the  vascular  changes  just  mentioned  has  been  the  object 
of  a  vast  deal  of  research  and  discussion,  but  we  are  still  ignorant  of  much  con- 
cernmg  these  processes.  The  modern  view,  however,  tends  steadily  toward  the 
belief  that  they  are  not  simply  the  result  of  a  passive  lesion  of  the  vessel  walls 
due  to  the  harmful  agent,  but  that  the  vascular  participation,  particularly  the 
part  played  by  the  capillary  endothelium,  is  essentially  an  active  process.     The 


86  AMERICAN  PRACTICE  OF  SURGERY. 

increased  permeability  of  the  vessel  wall  may  be  clue  to  an  active  contraction 
of  the  endothelial  cells  mstead  of  a  passive  stretching  and  thinning.  During 
inflammation  the  endothelial  cells  of  the  inflamed  area  become  larger  and  more 
prominent;  they  also  have  the  power  of  throwing  out  protoplasmic  processes 
and  of  phagocytosis.  Foreign  bodies  and  bacteria  may  be  taken  up  by  them. 
They  appear  to  be  increased  also  in  viscosity  during  inflammation,  and  the  slow- 
ing of  the  blood  stream  and  the  marginal  disposition  of  the  white  cells  may  be 
aided  by  this.  Further,  the  character  of  the  inflammatory  exudate  is  strong 
proof  that  it  is  not  simply  a  filtrate  but  a  secretion  produced  by  the  selective 
activity  of  the  endothelial  cells.  The  influence  of  the  vasomotor  nerve^  upon 
the  course  of  the  inflammation  may  be  taken  as  further  proof  of  this  view.  Al- 
though the  injurious  agent  may  cause  passive  changes  in  the  vessel  wall,  there 
are  abundant  reasons  for  believing  that  the  vascular  endothelium  actively  par- 
ticipates in  and  favors  the  occurrence  of  the  inflammatory  process. 

The  Cells  of  the  Inflamed  .4rea.— The  cellular  infiltration  in  and  about  the 
;seat  of  injury  is  of  a  less  simple  nature  than  was  formerly  believed.  More  de- 
tailed studies  of  the  cells  composing  it  show  that  the  problems  concerning  the 
origin,  nature,  and  function  of  the  round  cells  of  the  infiltration  are  not  so  easy 
of  solution  as  was  formerly  believed.  Consequently  much  discussion  has  been 
waged  over  these  questions.  While  they  cannot  as  yet  all  be  answered  posi- 
tively, we  have  made  at  least  some  progress  in  our  knowledge  concerning  the 
character  of  the  cellular  infiltration  or  exudate.  In  general,  it  may  be  said  that 
the  predominating  forms  of  cells  assembling  at  the  damaged  area  vary  accord- 
ing to  the  nature  and  location  of  the  injury.  As  a  rule,  five  types  of  round  cells 
are  characteristic  of  the  inflammatory  reaction— the  finely  granular  oxyphile 
(neutrophile)  polymorphonuclear  or  polynuclear,  the  coarsely  granular  oxyphile 
(eosinophile),  the  small  lymphocyte,  the  large  lymphocyte  (hyaline  cell),  and 
the  plasma  cell.  These  different  types  may  not  always  be  present  at  the  same 
time  and  in  the  same  proportions.  Although  at  the  height  of  the  reaction  the 
inflamed  area  is  usually  rich  in  cells,  the  variety  and  proportion  in  a  given 
case  may  vary  greatly  (see  Fig.  30). 

In  experimental  work  it  has  been  found  that  the  first  cells  to  move  toward 
the  tissue  lesion  are  the  eosinophile  wandering  cells.  The  neutrophile  poly- 
morphonuclear then  respond,  and  at  the  same  time  the  neutrophile  polymorpho- 
nuclears in  the  blood-vessels  begin  to  emigrate.  As  a  rule,  the  cells  of  the  in- 
filtration during  the  earlier  stages  of  inflammation  are  chiefly  the  neutrophile 
polymorphonuclears  or  polynuclears  with  an  occasional  eosinophile.  Under 
certain  conditions  the  number  of  eosinophiles  may  be  very  great  or  this  form 
may  even  predominate. 

As  the  inflammatory  process  increases  numerous  cells  of  the  lymphocyte 
type  appear,  at  first  collecting  about  the  periphery  of  the  inflamed  area,  while 
the  polymorphonuclear  cells  mass  themselves  in  the  centre  about  the  inflam- 


INFLAMMATION. 


87 


matory  agent.  Sometimes  the  lymphocyte  type  prevails  from  the  beginning  of 
the  process,  but  in  the  majority  of  cases  the  number  of  lymphocytes  increases 
as  the  course  of  the  inflammation  becomes  more  protracted.  The  source  of  the 
cells  of  the  lymphocyte  type  has  been  a  subject  for  much  speculation.  Their 
emigration  from  the  blood-vessels  has  been  denied  by  most  writers,  but  accord- 
ing to  recent  studies  such  a  process  undoubtedly  occm's.  Nevertheless,  it  is 
most  probable  that  the  chief  portion  of  the  cells  of  the  lymphocyte  type  foimd 
in  the  inflammatory  infiltration  does  not  come  from  the  vessels,  but  arises  in  the 
tissues  through  cell  division  of  pre-existing  lymphoid  cells  found  there.  The 
writer  agrees  strongly  with  Ribbert  as  to  the  source  of  the  lymphocj^tes. 

As  a  rule,  the  lymphocytes  usually  appear  in  such  numbers  as  to  be  easily 
recognizable  only  after  several  days  from  the  beginning  of  the  inflammation. 
They  may  be  scattered  among  the  polymorphonuclear  leucocytes,  or,  as  is 
more  common,  grouped  in  little  collections.     Ribbert  regards  these  lymphocyte 


Fig.  30. — Isolated  Cells  from  a  Granulating  Wound  (picrocarmine).  a,  Uninuclear  leucocytes;  a,, 
multinuclear  leucocyte;  b,  different  shapes  of  uninuclear  formative  cells;  c,  double-nucleated  formative 
cells;  c,,  multinucleated  formative  cells;  d,  formative  cells  in  the  process  of  tissue-formation;  e,  com- 
pleted connective  tissue,      x  500.      {After  Ziegler.) 

groups  as  representing  rudimentary  lymph  nodes,  which  under  the  influence  of 
the  inflammatory  reaction  become  hyperplastic  either  from  increased  cell  pro- 
liferation or  as  the  result  of  an  increased  number  of  lymphocytes  coming  to 
them  from  the  blood-vessels.  That  such  rudimentary  lymph  nodes  exist  every- 
where throughout  the  body  there  can  be  no  doubt.  Recent  studies  have  shown 
their  existence  in  practically  all  organs  and  tissues.  In  chronic  inflammation 
the  increasing  hyperplasia  of  these  lymphoid  areas,  with  the  development  of 
germ  centres  in  the  inflamed  area  in  tissues  where  lymph  nodes  with  germ  cen- 
tres are  not  found,  is  commonly  enough  seen  and  is  strong  evidence  in  support 
of  Ribbert's  views.  Hyperplasia  of  the  regional  lymph  nodes  as  a  part  of  a 
local  inflammatory  process  is  a  well-known  occurrence.     The  WTiter   accepts 


88  AMEPJCAX  PRACTICE  OF  SURGERY. 

Ribbert's  interpretation  of  these  lymphoid  collections  as  rudmientar}'  lymph 
nodes,  and  goes  a  step  further.  As  he  has  repeatedly  foimd  lymph  nodes  with 
germ  centres  m  newly  formed  inflammatory  tissues  on  the  pleiu-a,  peritoneum, 
and  in  peritoneal  adhesions,  etc.,  where  a  simple  hj^jerplasia  is  out  of  the  ques- 
tion, he  believes  also  in  a  new  formation  of  l}-mph  nodes  as  a  part  of  the 
inflammatory  process,  the  new  nodes  arising  from  the  proliferation  of  wander- 
ing lymphocytes.  Inasmuch  as  the  part  plaj^ed  by  the  lymphocytes  of  the. 
inflammatoiy  infiltration  is  not  phagocytic,  it  is  but  reasonable  to  believe 
that  they  must  possess  some  other  function.  Further  mention  of  this  will  be 
made  later. 

The  cells  of  the  large  lymphocyte  type  may  be  in  part  derived  from  the  small 
Ij-mphocytes  or,  as  is  more  probable,  are  for  the  chief  part  young  formative 
cells  derived  from  the  connective-tissue  cells  and  endothelium.  It  is  impossible 
to  decide  morphologically.  There  are  no  staining  methods  by  which  young 
formative  cells  may  be  distinguished  from  Ij-mphocytes.  Transition  forms  ap- 
pear to  exist  on  both  sides,  and  it  is  easily  understood  how  some  writers  regard 
these  cells  as  of  connective-tissue  origin,  while  others  regard  them  as  belonging 
to  the  white  cells  and  coming  from  the  blood-vessels. 

The  same  difficulty  of  interpretation  attends  the  plasma  cells.  These  are 
round  or  oval  cells  staining  deeply  with  methylene-blue  and  possessing  excen- 
trically  placed  nuclei,  which  have  a  chromatin  network  and  five  to  eight  chrom- 
atin granules.  As  the  protoplasm  is  more  compact  toward  the  periphery,  the 
nucleus  appears  to  be  surromided  by  a  lighter  zone.  ]\Iany  -m-iters  regard  these 
cells  as  a  variety  of  lymphocyte  and  claim  to  have  seen  them  emigrating  from 
the  blood-vessels.  Others  consider  them  to  be  of  coimective-tissue  origin.  As 
these  cells  show  elongated  forms  graduallj'  passing  into  cells  taking  part  in  the 
formation  of  scar  tissue,  and  as  the  protoplasm  of  the  plasma  cell  often  shows 
an  oxj'phile  hyaline  change,  the  writer  is  inclined  to  accept  the  view  of  their 
connective-tissue  origin,  not  upon  the  groimd  of  a  demonstrated  histogenesis, 
but  upon  that  of  an  apparent  participation  in  connective-tissue  formation.  The 
plasma  cells  are  particularly  abundant  in  chronic  infective  inflammations,  espe- 
cially in  those  characterized  by  much  scar-tissue  formation.  In  blastomycetic 
dermatitis  nearlj-  everj^  cell  of  the  infiltration  may  be  of  the  type  of  the  plasma 
cell.  Occasionally  the  plasma  cells  may  act  as  phagocytes,  the  ■RTiter  having 
seen  them  containing  blastomj'cetes. 

Multinuclear  as  well  as  mononuclear  giant  cells  (Fig.  30)  are  also  found  at 
times  in  the  cellular  infiltration,  particularly  in  chronic  infective  processes  and 
about  foreign  bodies.  In  part  they  may  be  deri^'ed  from  leucocytes,  but  the 
majority  are  of  connective-tissue  or  endothelial  origin.  Their  fmiction  appears 
to  be  essentially  protective. 

Summing  up,  we  may  say  that  the  cells  of  the  inflammatory  infiltration 
come  in  part  from  the  blood,  in  part  from  the  wandering  cells  of  the  tissues. 


INFLAMMATION.  89 

in  part  from  hyperplastic  or  newly  formed  lymph  nodes,  and  in  part  from 
the  proliferation  of  connective-tissue  and  endothelial  cells. 

Phagocytosis. — The  polymorphonuclear  leucocytes  and  the  derivativss  of 
the  fixed  connective-tissue  cells  and  endothelium  have  the  power  of  taking  up 
foreign  bodies,  particularly  bacteria.  To  a  less  degree  the  cells  of  the  large 
lymphocyte  type  show  also  the  same  property.  To  this  process  the  term  phago- 
cytosis is  applied;  the  cells  exhibiting  it  are  designated  phagocytes.  While  such 
a  property  is,  in  the  case  of  monocellular  animals,  chiefly  a  nutritive  function 
rather  than  protective,  it  has  evolved  in  the  multicellular  animals  to  a  function 
of  certain  forms  of  cells  serving  chiefly  as  protective  agents.  Through  chemo- 
taxis  the  cells  capable  of  phagocytosis  are  brought  to  the  place  where  their 
function  may  be  exerted  to  the  greatest  advantage.  Particularly  in  the  case  of 
bacterial  inflammations  does  this  function  serve  the  body  as  a  protective  factor. 
Great  numbers  of  the  bacteria  are  often  taken  up  by  the  phagocytes  and  rendered 
inert  or  are  destroyed  within  their  protoplasm  by  means  of  intracellular  chem- 
ical processes.  Like  the  other  protective  factors  of  the  inflammatory  process, 
phagocytosis  is  not  a  perfect  means  of  protection.  The  phagocytes  themselves 
may  be  destroyed  by  the  bacteria  they  have  taken  up,  or  they  may  fail  to  ren- 
der inert  those  they  contain  within  their  protoplasm  and  may  thus  disseminate 
them  throughout  the  body  by  means  of  the  lymph  or  blood  stream.  In  spite 
of  these  facts  the  unprejudiced  observer  must  realize  the  great  protective  value 
to  the  body  of  phagocytosis  as  it  ordinarily  occurs  in  local  pyogenic  inflamma- 
tions. The  view  that  it  is  only  an  accidental  utilization  of  a  function  primarily 
intended  for  nutrition  is  not  in  any  way  an  argument  against  an  appreciation 
of  its  utiUty. 

Extracellular  Protective  Factors. — Not  all  the  cells  of  the  inflammatory  in- 
filtration have  the  power  of  phagocytosis,  and  the  inference  naturally  arises 
that  they  must  possess  some  other  function  as  far  as  the  inflammatory  process 
is  concerned.  The  fact  that  the  blood  serum  and  the  serous  exudate  contain 
bactericidal  substances  (alexins)  has  been  demonstrated  by  many  investigators. 
The  source  of  the  alexins  has  been  ascribed  by  many  to  the  leucocytes,  the  anti- 
bodies arising  either  as  a  cell  secretion  or  as  a  product  of  cell  disintegration. 
That  the  leucocytes  contain  bactericidal  substances  has  been  shown  by  Buch- 
ner,  Hankin,  and  Loewit.  Organs  and  exudates  rich  in  leucocytes  yield  bacteri- 
cidal substances.  Blood  deprived  of  leucocytes  shows  a  lessening  of  its  bac- 
tericidal property.  Further,  Loewit  has  succeeded  in  extracting  from  washed 
leucocytes  a  bactericidal  substance  of  great  power. 

According  to  Kanthack  and  Hardy,  the  eosinophile  cells,  which  also  respond 
to  chemotactic  influences  but  are  not  phagocytic,  act  protectively  by  discharg- 
ing the  eosinophile  granules,  which  appear  to  affect  the  bacteria  so  that  they 
are  then  taken  up  by  the  phagocytes.  Stokes  and  Wegefarth  hold  that  in  the 
blood  serum   there   are   constantly  present  granules  resembling  those  of   the 


90  Ali'IERICAN   PRACTICE  OF  SURGERY. 

eosinophile  and  neutrophile  cells,  and  most  probably  derived  from  them.  When 
these  granules  are  filtered  out  of  the  blood  it  loses  its  power  of  destroying  bac- 
teria, but  this  property  may  be  restored  by  adding  leucocytes  and  granules. 
The  researches  of  the  last  decade  have  made  it  evident  that  the  cells  of  the 
leucocyte  type  afford  the  body  protection  not  only  by  means  of  phagocytosis, 
but  by  producing  and  giving  to  the  blood  serum  or  inflammatory  exudate  bac- 
tericidal substances.     Antitoxic  substances  may  be  produced  in  the  same  way. 

Further,  the  leucocytes  of  the  inflammatory  mfiltration  may  prevent  the 
spread  of  a  harmful  agent  by  means  of  a  denselj^  packed  cell  barrier  formed 
about  the  primary  centre  of  injury.  Dming  the  process  of  repair  the  white 
cells  may  also  serve  as  a  source  of  food  to  the  formative  cells,  the  latter  often 
containing  them  in  various  stages  of  disintegration. 

The  Fluid  Exudate. — That  there  is  a  direct  relationship  between  the  forma- 
tion of  the  fluid  exudate  and  the  cause  of  the  tissue  lesion  is  shown  by  the  fact 
that  the  foniier  increases  in  amount  and  varies  in  character  with  the  nature 
and  severity  of  the  irritation  produced.  The  location  of  the  injury  and  the 
general  condition  of  the  bod}'  and  nervous  system  are  also  factors  influencing 
the  amount  and  character  of  the  fluid  exudate.  As  stated  above,  there  are 
very  good  reasons  for  believing  that  the  fluid  exudate  is  not  a  filtrate  pure  and 
simple,  but  is  a  secretion  of  the  vascular  walls.  Only  by  means  of  such  a  view 
is  it  possible  to  explain  the  character  of  the  fluid,  its  difference  in  composition 
from  the  blood  serum,  and  its  varying  character  in  different  parts  of  the  body. 
Such  differences  can  be  interpreted  only  as  an  indication  of  a  selective  activity 
on  the  part  of  the  endothelium. 

In  the  fluid  exudate  there  are  present  both  antibacterial  and  antitoxic  sub- 
stances, but,  as  mentioned  above,  these  are  most  probably  formed  by  the  cells 
and  set  free  into  the  fluid  exudate.  On  a  body  surface  the  fluid  exudate  may 
wash  away  or  dilute  the  mjm-ious  agent.  In  the  tissue  spaces  the  inflammatory 
ojdema  may  also  serve  a  similar  purpose.  The  formation  of  fibrm  in  the  exu- 
date may  also  be  a  factor  of  advantage  in  limiting  the  spread  of  the  bacteria. 
Since  its  production  is  associated  with  the  disintegration  of  leucocytes  and 
others  of  the  wandering  cells,  it  may  be  associated  with  the  production  of  anti- 
bodies or  ferments  having  the  power  of  destruction  or  digestion  of  the  irritant. 
Further,  the  fluid  exudate  may  also  serve  in  increasing  the  nutrition  of  the 
inflamed  area  and  in  this  way  promote  cell  growth. 

Part  Played  by  the  Nervous  System.— Wh\[e  acute  inflammatory  processes 
may  occur  independently  of  the  central  nervous  system,  the  vessels  of  the  in- 
flamed area  either  responding  directly  to  the  irritant  or  through  the  peripheral 
nerves,  it  has  been  shown  experimentally  that  removal  of  the  vaso-constrictor 
influence  accelerates  an  inflammatory  reaction,  while  removal  of  the  vaso- 
dilator influence  retards  it.  Further,  influences  from  the  central  nervous 
system  alone,  without  the  occurrence  of  a  local  injury,  may  set  into  action  all 


INFLAMMATION.  91 

the  phenomena  of  local  inflammation.  Such  inflammatory  reactions  of  nervous 
origin  may  be  seen  in  cases  of  hysteria  and  in  hypnosis.  It  is  also  probable 
that  some  of  the  so-called  "sympathetic  inflammations"  are  in  reality  referred 
processes  having  a  central  nervous  origin.  Inflammatory  reactions  may  thus 
be  produced  along  other  branches  of  a  nerve  supplying  a  region  in  which  there 
is  a  primary  inflammation.  Likewise,  areas  whose  nervous  supply  comes  from 
the  same  part  of  the  brain  or  cord  as  that  supplying  an  inflamed  part  may 
similarly  be  involved.  Such  questions,  however,  need  more  thorough  investiga- 
tions before  we  can  unhesitatingly  accept  such  a  referred  origin. 

Of  the  existence  of  purely  trophic  nerves  there  is  as  yet  not  a  shadow  of 
absolute  proof.  The  inflammatory  changes  so  often  seen  in  parts  devoid  of 
nervous  supply,  as  the  result  of  the  section  or  complete  destruction  of  the  spinal 
cord  or  nerves  supplying  the  part,  may  be  explained  as  the  result  of  the  tend- 
ency of  such  tissues  to  receive  trauma  in  connection  with  their  lowered  tone, 
due  to  the  lack  of  exercise,  disturbed  circulation,  etc. 

Part  Played  by  the  Lymphatic  System. —  The  important  role  played  in  the 
local  inflammatory  process  by  the  rudimentary  lymph  nodes  scattered  through- 
out all  tissues  has  been  mentioned  above.  The  larger  regional  lymph  nodes  and 
lymphatics  have  also  an  important  part  in  inflammation,  both  clinicaUy  and 
pathologically.  The  lymph  channels  leading  from  the  inflamed  area  become 
dilated  as  the  result  of  the  increased  amount  of  lymph  coming  from  the  inflamed 
region.  Since  this  lymph  may  contain  the  infective  agent  or  chemical  products 
formed  by  it,  the  endothelium  of  the  lymphatics  in  question  often  becomes 
hypertrophic  and  may  also  exercise  a  phagocytic  function.  It  is  also  an  open 
question  if  such  hypertrophic  endothelial  cells  do  not  produce  antibodies.  There 
is  also  an  increased  number  of  leucocytes  in  the  lymph  coming  from  the  inflamed 
part,  and  some  of  these  may  contain  the  injiu'ious  agent.  Further,  large  num- 
bers of  red  blood  cells  may  be  found  in  such  lymph . 

The  lymph  nodes  receiving  such  lymph  become  enlarged  and  often  painful. 
On  section  they  are  softer  and  moister  than  normal  nodes,  and  usually  are 
more  or  less  congested.  On  microscopical  examination  they  present  a  condition 
of  congestion,  oedema,  and  more  or  less  hyperplasia  of  the  lymphoid  and  endo- 
thelial elements.  The  lymph  sinuses  may  at  times  be  packed  full  of  large  hya- 
line cells  of  endothelial  type.  These  especially  are  found  to  be  acting  as  jDhago- 
cytes,  and  contain  red  blood  cells,  blood  pigment,  leucocytes,  or  bacteria. 
Numerous  mitoses  are  found  throughout  the  lymphoid  tissue.  Leucocytes 
containing  bacteria  may  also  be  foimd  in  the  lymphoid  areas  as  well  as  in  the 
sinuses.  That  these  bacteria  are  dead  or  are  reduced  in  virulence  is  evident 
from  the  fact  that  in  the  great  majority  of  cases  they  do  not  multiply  or  produce 
local  cell  necrosis.  Wlien  the  infective  agent  is  of  high  virulence  small  areas 
of  cell  degeneration  or  necrosis  are  often  found  in  the  sinuses  or  lymphoid  tissue, 
but  the  fact  that  the  bacteria  often  soon  die  out  in  these  areas  without  causing 


92  AMERICAN  PRACTICE  OF  SURGERY. 

further  changes  may  also  be  taken  as  strong  evidence  of  the  protective  functions 
exercised.  Occasionally  these  are  inadequate  and  the  lymph  nodes  may  be- 
come the  seat  of  secondary  inflammations,  equalling  or  exceeding  the  primary 
in  severity. 

The  blocking  of  the  lymph  sinuses  through  the  proliferation  and  hyperplasia 
of  the  endothelial  cells  lining  them  serves  as  a  barrier  to  the  further  spread  of 
the  infective  agent,  and  gives  opportimity  for  the  exercise  of  the  function  of 
phagocytosis  and  the  formation  of  antibodies.  The  large  mononuclear  cells 
(hyaline  cells)  lying  in  the  meshes  of  the  reticulum  of  the  lymph  sinuses  often 
contain  great  numbers  of  disintegrating  red  blood  cells  and  particles  of  blood, 
pigment.  They  also  take  up  disintegrating  leucocytes.  The  number  of  eosin- 
ophile  cells  is  usually  increased  in  the  regional  lymph  nodes  during  local  in- 
flammatory processes.  They  are  most  numerous  at  the  borders  of  the  lymphoid 
areas  along  the  sinuses.  The  active  proliferation  of  lymphocytes  may  also  be 
interpreted  as  protective. 

In  the  case  of  very  virulent  organisms  or  when  the  resistance  of  the  body 
is  lowered,  the  injurious  agent  may  extend  along  the  lymph  vessels,  exciting 
an  inflammatory  reaction  along  their  course  {ascending  lymphangitis),  and  may 
also  involve  the  nodes.  The  latter  may  present  secondary  foci  without  any 
signs  of  the  intermediate  involvement  of  the  lymphatics.  Primary  cryptogenic 
infective  inflammations  are  also  not  uncommon  in  lymph  nodes.  Such  events 
simply  go  to  show  that  the  body's  protective  powers  are  not  always  adequate, 
and  that  at  times  the  infective  agent  may  conquer  them  and  the  process  of 
tissue  injury  and  reaction  go  on  until  the  organism  either  finally  overcomes  or 
succumbs. 

Reparative  Factors. — As  we  have  already  seen,  the  slightest  possible  tissue 
lesion  excites  chiefly  a  formative  reaction — the  cells  at  or  about  the  seat  of 
injury  divide  and  replace  those  killed  by  the  injurious  agent.  In  more  exten- 
sive and  severe  tissue  lesions,  particularly  those  due  to  infective  agents,  the 
formative  reaction  may  be  longer  delayed,  owing  to  the  progressive  injury  to 
the  tissues  about  the  growing  colony  of  micro-organisms.  Nevertheless,  imder 
all  conditions  cell  proliferation  is  so  constant  a  factor  of  the  inflammatory  reac- 
tion that  it  can  be  regarded  not  as  a  sequela  alone,  but  as  an  essential  part  of 
the  process.  The  tissue  destroyed  may  be  replaced  by  tissue  of  the  same  kind 
(regeneration)  or  by  fibrous  connective  tissue  (repair,  cicatrization). 

Regeneration  (Restitutio  ad  integrum).  — "The  process  of  regeneration  is 
dependent  upon  the  kind  of  tissue  involved,  the  extent  and  severity  of  the 
lesion,  and  the  mode  of  action  of  the  injurious  agent.  If  the  cells  of  an  inflamed 
area  are  but  slightly  damaged  and  retain  their  nuclei  intact,  they  are  quickly 
restored  as  soon  as  the  injurious  agent  ceases  to  act.  When  single  cells  are 
lost  without  disturbance  of  the  tissue  organization  as  a  whole,  there  occurs 
in  the  majority  of  tissues  and  organs  a  rapid  replacement  through  the  division 


INFLAMMATION.  93 

of  the  neighboring  cells.  The  connective  tissues,  the  epithelium  of  the  skin  and 
mucous  membranes,  liver  and  kidney,  have  the  greatest  regenerative  capacity; 
while  ganglion  cells,  bone  cells,  cartilage  cells,  and  heart  muscle  have  little  or 
none.  Cell  proliferation  may  begin  as  early  as  eight  hours  after  the  lesion,  but 
is  usually  recognizable  at  from  twenty-four  to  forty-eight  hours.  Under  certain 
conditions,  particularly  in  the  case  of  chronic  inflammations,  the  process  of 
regeneration  goes  beyond  the  degree  necessary  for  the  restoration  of  the  part 
to  its  original  state,  and  there  result  inflammatory  overgrowths  and  hj^per- 
plasias,  which  may  be  of  no  service  to  the  body  or  even  of  a  disadvantage.  Such 
hyperplasias  are  often  found  about  the  margins  of  slowly  healing  ulcers. 

Repair. — When  the  tissue  injury  is  so  marked  as  to  cause  a  break  in  the 
continuity  of  the  mesodermal  tissues,  there  is  an  incomplete  regeneration  in 
that  there  is  formed  at  the  seat  of  injury  a  new  tissue,  which  differs  more  or 
less  from  the  original  tissue  and  shows  also  a  more  or  less  marked  loss  of  func- 
tion. This  new  tissue  arises  through  the  proliferation  of  the  fixed  connective- 
tissue  cells  and  endothelium  about  the  seat  of  injury.  It  consists  essentially 
of  proliferated  connective-tissue  cells  (fibroblasts)  and  new  capillary  loops,  and 
is  infiltrated  with  mono-  and  polynuclear  leucocytes.  Formative  cells  arising 
from  such  tissues  as  the  periosteum,  bone-marrow,  or  muscle  are  known  as 
osteoblasts,  chondroblasts,  and  sarcoblasts,  accordinglj^  as  they  form  bone,  carti- 
lage, or  muscle.  In  the  case  of  injury  to  epithelial  tissue,  newly  formed  epi- 
thelial cells  may  also  be  present  in  the  formative  tissue.  The  formative  cells 
themselves  have  the  power  of  amoeboid  movement  and  may  appear  as  wander- 
ing cells.  They  are  sometimes  multinuclear  or  may  appear  as  mononuclear 
giant  cells.  They  vary  greatly  in  form,  are  usually  branched,  and  have  large 
bright  oval  nuclei  which  do  not  stain  deeply,  thereby  resembling  the  nuclei  of 
epithelial  cells.  For  that  reason  formative  cells  are  often  called  epithelioid 
cells. 

The  formative  tissue  is  known  as  granulation  tissue.  It  is  extremelj'  vascu- 
lar; hence  to  the  naked  eye  it  is  red  in  color.  The  vessels  (newly  formed  capil- 
lary loops)  are  characterized  by  a  wide  lumen  and  a  wall  consisting  of  a  single 
layer  of  endothelial  cells,  which  usually  appear  hypertrophic.  The  new  capil- 
laries arise  as  offshoots  from  the  vessels  in  or  near  the  inflamed  area.  The 
new  capillaries  extend  out  into  the  necrotic  tissue  or  exudate  at  the  seat  of  in- 
flammation. Between  them  lie  the  fibroblasts,  embedded  in  a  fluid  or  semifluid 
intercellular  substance  infiltrated  with  leucocytes.  As  the  fibroblasts  increase 
in  number  and  come  to  lie  more  closely  together  and  to  supersede  the  leuco- 
cytes, fine  fibrillse  begin  to  appear  in  the  intercellular  substance.  As  this 
differentiation  of  the  intercellular  substance  takes  place,  the  formative  cells 
become  smaller,  the  blood-vessels  contract,  the  granulation  tissue  gradually 
becomes  changed  into  scar  tissue,  and  the  process  of  repair  comes  to  an  end. 
In  the  scar  tissue  small  groups  of  lymphoid  cells  may  remain  for  a  long  time 


94  AMERICAN  PRACTICE  OF  SURGERY. 

after  all  other  signs  of  inflammation  have  disappeared.     They  may  be  inter- 
preted as  persistent  hyperplastic  rudimentary  lymph  nodes. 

The  phenomena  of  cell  proliferation  are  essentially  reparative,  but  they  are 
also  to  some  extent  protective.  The  zone  of  granulation  tissue  about  an  ab- 
scess or  at  the  bottom  of  an  ulcer  may  act  as  a  barrier  against  the  further  spread 
of  the  infective  agent  into  the  surrounding  healthy  tissues.  The  great  num- 
ber of  thin-walled  vessels  with  their  active  endothelial  cells  favors  the  produc- 
tion of  a  serous  fluid  containing  antibodies.  Afanassieff  has  shown  that  the 
action  of  the  cells  and  serum  of  a  healthy  granulation  tissue  is  bactericidal. 
Nevertheless,  in  some  cases  the  formative  tissue  may  become  necrotic  as  the  re- 
sult of  increased  virulence  of  the  infective  agent,  secondary  or  mixed  infection, 
or  weakened  resistance  due  to  circulatory  disturbances,  general  ansemia,  etc. 
Moreover,  granulation  tissue  cannot  restore  the  lost  function  of  the  part  de- 
stroyed. Again,  in  some  cases  the  formation  of  granulation  tissue  is  so  excessive 
as  to  be  of  disadvantage  or  even  an  injury  to  the  organism,  while  in  other  cases 
still  the  resulting  contraction  of  the  scar  tissue  may  cause  additional  functional 
disturbances.  The  reparative  processes,  like  the  protective,  are  also  imperfect 
and  inadeciuate. 

6.  Symptomatology. 

The  classical  symptoms  of  the  inflammatory  process  (calor,  rubor,  dolor, 
tumor,  and  fundio  Icesa)  may  be  manifested  when  the  inflammation  is  located 
upon  the  sm-face  of  the  body. 

Calor  (Heat).— The  increased  warmth  of  an  inflamed  area  located  upon  the 
body  surface  is  due  to  the  active  hypeisemia,  the  dilated  blood-vessels  favoring 
the  greater  amount  of  heat  dispersion.  The  inflamed  part  becomes  warmer  than 
it  was  before  only  as  the  result  of  the  increased  blood  flow.  Although  many 
writers  have  believed  in  a  local  increase  of  heat  production,  the  most  careful 
measurements  have  failed  to  demonstrate  such  a  local  rise  in  temperature,  the 
temperature  of  the  affected  area  never  being  higher  than  that  of  the  blood  in 
the  left  ventricle.  The  temperature  of  the  body  as  a  whole  may  be  raised 
(fever).  'While  measurements  may  fail  to  show  any  such  increased  local  heat 
production,  it  is  not  at  all  improbable  that  such  does  occur  as  the  result  of 
molecular  changes  due  to  the  action  of  the  inflammatory  agent.  Such  local 
increased  heat  production  may  easily  be  compensated  by  the  local  increase  of 
heat  dispersion,  so  that  the  local  temperature  may  be  maintained  at  no  greater 
height  than  that  of  the  internal  organs.  The  increased  temperature  may  serve 
a  protective  function  in  inhibiting  or  killing  off  the  infective  agent. 

Rubor  (Redness). — This  is  the  direct  result  of  the  hypersemia.  At  fii'st,  the 
inflamed  area  is  uniformly  bright  red;  later,  as  the  blood  current  slows  and  a 
condition  of  stasis  supervenes,  the  color  becomes  darker  or  even  bluish,  although 
around  the  periphery  there  may  persist  a  bright-red  zone.     The  central  portion 


INFLAMMATION.  95 

of  the  damaged  area  may  be  antemic  and  present  a  grayish  or  yellowish  color, 
while  around  the  periphery  there  is  a  surrounding  zone  bright  red  in  color. 
As  the  new  capillaries  extend  out  into  the  necrosed  area  the  latter  gradually 
becomes  red.  During  the  course  of  the  inflammatory  process  the  diffuse  red 
color  often  shows  a  mottling  of  darker  spots,  which  do  not  become  pale  when 
pressed  upon.    They  are  the  result  of  scattered  hemorrhages. 

Dolor  (Pam). — The  local  pain  and  tenderness  may  be  explained  as  the  result 
of  the  increased  pressure  exerted  upon  the  nerves,  their  direct  irritation  by 
chemical  products,  or  their  direct  participation  in  the  inflammatory  process. 
In  the  case  of  inflammatory  conditions  of  the  internal  organs,  less  often  of  the 
body  surface,  the  pain  is  often  referred  to  other  parts.  Usually  this  is  to 
parts  supplied  by  branches  of  the  same  nerve  as  that  supplying  the  inflamed 
area. 

Tumor  (Swelling). — The  swelling  of  the  inflamed  area  is  easily  explained  by 
the  increased  amount  of  blood  in  the  part,  the  assemblage  of  cells,  the  increased 
formation  of  lymph,  and  the  swelling  of  the  tissue  elements.  The  lymph  stasis 
(inflammatory  oedema)  of  the  inflamed  area  plays  a  very  prominent  role  in  the 
enlargement  of  the  inflamed  tissues.  It  is  due  in  part  to  the  changes  occurring 
in  the  regional  lymphatics  and  lymph  nodes,  and  in  part  to  the  diminished 
elasticity  of  the  inflamed  tissues. 

Altered  Function  (Functio  La?sa). — The  alteration  or  loss  of  function  of  the 
inflamed  part  is  the  result  chiefly  of  the  tissue  lesion,  the  injury  or  destruction 
of  the  parenchymatous  cells,  the  result  of  pressure,  etc. 

Constitutional  Ssonptoms. — Even  in  the  simple,  non-infective  forms  of  in- 
flammation there  may  be  more  or  less  constitutional  disturbances,  such  as  gen- 
eral malaise,  headache,  fever,  etc.,  but  these  symptoms  are  exliibited  to  the  most 
marked  degree  in  the  case  of  pyogenic  inflammations.  High  fever,  pain  in  the 
bones  and  joints,  headache,  gastro-intestinal  disturbances,  nervous  disturbances, 
delirium,  etc.,  may  characterize  the  clinical  course  of  these  processes.  These 
sjmiptoms  are  due  to  the  absorption  of  toxic  substances  {piomdins  or  toxins) 
from  the  inflammatory  focus.  To  this  general  intoxication  the  terms  toxinamxa 
or  septicwmia  are  usually  applied.  The  poisons  absorbed  in  these  conditions 
may  cause  a  degeneration  or  necrosis  of  the  epithelium  of  the  liver  or  kidneys, 
and  the  symptoms  of  acute  urtemia  may  be  added  to  the  others.  In  fatal  pyo- 
genic infections  (septiccemia  or  pymnia)  the  kidney  lesion  is  usually  the  imme- 
diate cause  of  death  {acute  degenerative  nephritis).  The  effects  of  such  intoxi- 
cations upon  other  organs  —  as  the  heart  (cardiac  insufficiency,  "heart  failure"), 
for  example  —  may  also  be  added  to  the  general  clinical  picture.  In  the  case  of 
chronic  inflammations  a  chronic  intoxication  may  lead  to  secondary  chronic 
inflammatory  processes  in  the  liver,  kidney,  or  other  internal  organs.  Chronic 
suppurative  processes  may  give  rise  to  a  general  amyloid  degeneration,  with  its 
resulting  clinical  picture. 


96  AMERICAN  PRACTICE  OF  SURGERY. 

7.  Involvement  of  the  Organism  in  the  Inflammatory  Process. 

The  inflammatory  process  is  essentially  a  local  reaction  to  local  injury. 
While  the  significance  of  the  term  might  be  extended  to  include  the  general 
processes  of  protection  and  defence  (immunity)  of  the  body  against  infections 
or  mtoxications,  it  is  inadvisable  to  do  so  and  better  to  reserve  the  term  for 
the  local  reaction  to  injury.  Further,  in  the  case  of  general  infection  or  in- 
toxication of  the  body,  the  protective  reaction  is  deprived  of  the  greater  part 
of  the  phenomena  (hypersemia,  chemotaxis,  emigration,  serous  exudation,  etc.) 
that  characterize  the  local  reaction  to  injury.  In  the  general  reaction  the  chief 
phenomenon  is  the  production  of  antibodies. 

As  a  result  of  the  local  process,  however,  the  general  protective  influences 
are  often  called  into  action,  and,  indeed,  must  be  considered  an  essential  part 
of  the  former.  This  is  particularly  the  case  when  the  inflammation  is  due  to 
infective  micro-organisms  producing  toxic  substances,  that  when  taken  up  into 
the  blood  and  lymph  cause  injury  to  the  cells  of  the  body.  Such  poisons  may 
arise  from  the  growth  of  saprophytic  micro-organisms  in  the  necrotic  tissue 
or  in  the  exudates  at  the  site  of  the  primary  lesion  (saprcemia),  or  from  toxins 
produced  there  by  pathogenic  organisms  (toxincemia,  septicccmia) . 

The  exciting  cause  (bacteria)  may  be  spread  through  the  body  by  means  of 
the  lymph  or  blood  stream  Qmcteriamia) ,  and  give  rise  to  secondary  foci  of 
tissue  injury  and  reaction  {lymphogenous  and  hcvmatogenous  metastasis).  In  the 
case  of  pyogenic  organisms  the  formation  of  secondary  abscesses  is  known  as 
pycania.  The  entrance  into  the  blood  of  pathogenic  micro-organisms  and  their 
growth  there  with  the  production  of  a  general  intoxication,  but  without  the 
formation  of  secondary  local  inflammations,  are  usually  called  septiccemia, 
although  this  term  is  also  ajjplied  to  the  condition  of  toxingemia  alone  without 
the  presence  of  bacteria  in  the  blood.  A  combination  of  pysemia  and  septi- 
cemia may  also  occur  {septicopya:mia  and  pyosepthannia) . 

The  general  organism  ma}-  also  be  affected  in  other  ways  by  the  local  inflam- 
matory process.  In  certain  organs  of  the  body  auto-intoxications  may  be  pro- 
duced as  the  result  of  disturbed  function  due  to  inflammation.  In  the  case  of 
glands  having  an  internal  secretion,  inflammatory  processes  may  lead  to  severe 
or  fatal  disturbances  of  general  metabolism.  The  interdependence  of  the  fmic- 
tion  of  one  organ  with  that  of  another  may  also  be  disturbed  as  the  result  of 
local  inflammation. 

8.  Classification  of  Inflammations. 

According  to  their  etiology  inflammations  may  be  classed  in  general  as 
traumatic,  thermal,  toxic,  infective,  etc.  The  non-infective  inflammations  are 
often  spoken  of  as  simple  or  aseptic.  The  terms  idiopathic,  sthenic,  and  asthenic 
inflammations  are  no  longer  used. 


INFLAMMATION.  97 

Inflammations  are  classed  as  acute,  subacute,  and  chronic,  according  to  their 
course.  AVhen  the  process  rapidly  arises  and  quickly  passes  it  is  termed  acute; 
when  slowly  progressive  over  a  long  period  of  time  it  is  classed  as  chronic. 
Processes  occupying  an  intermediate  station  may  be  known  as  subacute.  In 
general,  acute  inflammations  are  characterized  by  abundant  exudation,  chronic 
inflammations  by  abundant  production  of  connective  tissue.  Such  a  distinction 
does  not,  however,  always  hold  good,  but  applies  to  the  great  majority  of  cases. 

According  to  their  location  inflammations  may  be  classed  as  superficial, 
parenchymatous,  or  interstitial.  Superficial  inflammations  are  those  situated 
upon  a  body  surface.  Upon  mucous  membranes  the  inflammation  is  more 
often  designated  a  catarrh.  A  parenchymatous  inflammation  is  one  character- 
ized by  degeneration  or  necrosis  of  the  parenchymatous  cells  of  an  organ,  while 
an  interstitial  inflammation  is  one  in  which  the  connective  tissue  or  supporting 
stroma  of  the  organ  is  chiefly  involved.  Such  a  distinction  is  somewhat  arti- 
ficial, since  all  inflammatory  processes  necessarily  are  interstitial,  the  interstitial 
reaction  following  and  being  dependent  upon  a  damage  to  the  parenchymatous 
cells.  As  a  rule,  the  term  parenchymatous  inflammation  is  applied  to  conditions  of 
tissue  lesion  (degeneration  or  necrosis)  in  which  the  inflammatory  reaction  may 
not  yet  have  appeared,  so  that  interstitial  changes  are  not  yet  apparent.  Since 
the  term  interstitial  has  largely  come  to  be  used  as  a  synonym  for  productive 
inflammation, — that  is,  those  inflammations  which  are  characterized  particularly 
by  proliferation  of  the  connective-tissue  cells, — it  serves  to  designate  a  certain 
class  of  inflammatory  processes  more  or  less  chronic  in  nature  and  due  chiefly  to 
chronic  intoxications. 

The  character  of  the  tissue  lesion  also  serves  as  a  basis  for  a  classification 
of  inflammation.  When  tissue  degenerations — such  as  cloudy  swelling,  hy- 
dropic, fatty,  or  mucoid  degeneration — are  more  prominent  as  the  tissue  lesion 
than  is  the  inflammatory  reaction,  the  inflammation  is  usually  styled  degener- 
ative. Since  those  forms  which  are  characterized  by  mucoid  degeneration  usu- 
ally occur  upon  mucous  membranes,  they  are  embraced  in  the  more  general  des- 
ignation of  catarrh. 

Tissue  lesions  of  the  nature  of  a  marked  necrosis  give  to  the  inflammatory 
process  a  necrotic  character.  The  necrosis  may  be  of  the  type  of  simple,  coagu- 
lation, liquefaction,  caseation,  or  gangrenous.  A  coagulation  necrosis  occurring 
upon  a  surface,  particularly  upon  a  mucous  membrane,  is  usually  styled  diph- 
theritic, or  the  entire  process  may  be  known  as  diphtheritis.  A  fibrinous  exu- 
dation is  usually  associated  with  the  latter  process.  Secondary  infection  of  the 
tissue  lesion  Avith  saprophytic  bacteria  gives  to  the  process  the  type  of  a  gan- 
grenous inflammation.  A  prunary  gangrenous  inflammation  may  also  occur. 
Infection  with  the  gas-forming  bacteria  gives  rise  to  an  emphysematous  gangrene. 
Caseous  necrosis  is  found  particularly  in  the  case  of  certain  chronic  infective 
inflammations,  tuberculosis,  syphilis,  etc. 


98  AMERICAN   PRACTICE   OF   SURGERY. 

The  classification  according  to  the  character  of  the  exudation  serves  a  very 
practical  purpose  both  clinically  and  pathologically.  There  may  be  distm- 
guished,  first,  a  serous  inflammation,  characterized  by  the  production  of  a  more 
or  less  abundant  fluid  exudate  containing  relatively  but  few  cells.  When  the 
percentage  of  fibrin  is  so  high  as  to  make  it  a  very  prominent  featme  of  the  exu- 
date, it  is  classed  as  fibrinmi-s.  When  the  cellular  infiltration  of  the  inflamed 
area  is  but  slight,  it  is  spoken  of  as  a  small-celkd  infiltration;  but  when  the  cells 
are  so  nmnerous  as  to  pack  densely  the  area,  or  when  occurring  in  such  mmibers 
in  the  fluid  exudate  as  to  give  it  a  thick,  cloudy  appearance,  the  inflammation 
is  styled  ipundent.  The  liquefaction  of  the  piu-ulent  area  is  knowoi  as  suvpura- 
tion,  and  the  resulting  mixtiue  of  leucocytes,  tissue  fragments,  etc.,  is  called 
pus.  An  exudate  containing  large  numbers  of  red  blood  cells  may  be  styled 
hemorrhagic.  Various  combinations  of  these  forms  may  occur,  such  as  sero- 
purulent,  serofibrinous,  fibrinopurulent,  etc. 

Inflammations  are  also  often  classed  according  to  their  mode  of  resolution 
or  the  sequela?  of  the  inflammatory  process.  Some  inflammations  cause  marked 
atrophy  of  the  part  affected  {atrophic  infiammations) ;  others  are  characterized 
by  marked  proliferation  of  the  comiective-tissue  stroma  {interstitial,  productive, 
hyperplastic,  indurative,  cirrhotic,  etc.).  Serous  sm-faces  may  become  greatly 
thickened  or  opposing  sm-faces  may  become  vmited  tlu^ough  the  organization  of 
the  exudates  gluing  them  together  {adhesive  or  plastic  infiammation).  In  the 
case  of  certain  chronic  uifections,  large  tmnor-like  growths  of  granulation  tissue 
may  be  produced  {gramdoma).  Marked  sequete  of  such  a  nature  as  to  charac- 
terize the  inflammation  occur  more  often  as  the  result  of  protracted  chronic 
inflammatory  processes  than  as  the  result  of  the  healing  of  acute  processes. 

Varieties  of  Inflamm.a.tion. 


Etiology. 

Chronicity. 

Location. 

Tissue-Lesion. 

Exudation. 

Sequelae. 

Traumatic 

Acute. 

Superficial  (ca- 

Degenerative. 

Serous     (catar- 

Atrophic. 

(simple). 

Subacute. 

tarrh). 

Necrotic. 

rhal). 

Hyperplastic 

Thermal. 

Chronic. 

Parenchyma- 

1. Simple. 

Fibrinous. 

(productive). 

Toxic. 

tous. 

2.  Diphtheritic!  Purulent    (sup- 

Indurative. 

Infective. 

Interstitial. 

3.  L  iquefactiouj      purative). 
(sup  pur  a-  Hemorrhagic. 

Adhesive. 
Granuloma. 

tion). 

4.  Caseous. 

5.  Gangrenous. 

9.  Resolution  of  the  Infl.\mmatory  Reaction. 

That  the  inflammatory  reaction  be  brought  to  a  standstill  and  the  process 
terminate  in  healing,  it  is  necessary  that  the  exciting  cause  should  cease  to  act, 
the  necrotic  tissue  and  exudate  be  disposed  of,  the  nutritive  and  circulatory 
conditions  be  restored  to  the  normal,  and  the  tissue  defect,  if  any,  be  repaired. 

Cessation  of  Cause. — The  action  of  the  injurious  agent  may  be  of  very 


INFLAMMATION.  99 

short  duration,  as  in  the  case  of  certain  forms  of  trauma.  In  the  case  of  poisons 
the  pouring  out  of  a  fluid  exudate  may  dilute  the  irritant  or  wash  it  away.  In 
infective  inflammations  the  bacteria  may  be  washed  away  by  the  fluid  exudate, 
cast  off  with  tissue  sloughs,  or  rendered  non-virulent,  or  are  killed  by  the  phago- 
cytes and  the  extracellular  bactericidal  substances  formed  during  the  inflamma- 
tory reaction.  The  irritant  substances  formed  by  bacteria  may  be  neutralized 
by  antitoxins. 

Disposal  of  Necrotic  Tissue. — Dead  cells  or  tissue  elements  may  be  cast  off 
as  a  slough,  liquefied,  in  part  absorbed  and  utilized  as  nutriment,  or  replaced 
by  granulation  tissue  (organization).  The  sequestration  and  absorption  of 
necrotic  tissue  require  a  certain  amount  of  time.  The  greater  the  amount  of 
dead  tissue,  the  slower  the  removal  and  the  more  protracted  the  healing  process. 
As  a  rule,  the  inflammation  persists  as  long  as  necrotic  tissue  is  present. 

Disposal  of  the  Exudate. — Serous  exudates  may  be  quickly  taken  up  by 
the  l3miph  stream.  Fibrinous  exudates,  when  soon  liquefying,  may  also  be 
quickly  absorbed.  Firm  fibrinous  exudates  and  large  collections  of  pus  are  re- 
moved with  difficulty  and  prolong  the  course  of  the  inflammation.  Exudates 
upon  a  surface  may  be  cast  off.  Firm  exudates  often  become  liquefied  and  are 
then  more  easily  absorbed.  When  liquefaction  does  not  take  place,  the  exu- 
date acts  as  a  foreign  body  and  prolongs  the  inflammation,  eventually  becoming 
replaced  by  granulation  tissue  (organization).    Scar  tissue  is  ultimately  formed. 

Restoration  of  the  Normal  Circulation. — With  the  cessation  of  the  action 
of  the  injurious  agent  and  the  removal  of  dead  tissue  and  exudates  and  the 
establishment  of  reparative  processes,  the  hyperajmia  of  the  vessels  of  the  in- 
flamed area  subsides,  the  leucocytosis  and  emigration  diminish,  and  the  number 
of  wandering  cells  in  the  tissue  spaces  becomes  lessened.  Ultimately  the  normal 
vascular  conditions  are  restored,  and  the  nutrition  of  the  part  again  becomes 
normal.  Wlien  the  irritant  is  of  slight  intensity  and  diu-ation,  as  in  the  case  of 
a  slight  tramna,  bmn,  corrosive  poison,  etc.,  the  restoration  of  the  vessels  may 
take  place  in  a  very  short  time.  In  the  case  of  more  extensive  tissue  lesions, 
the  normal  vascular  conditions  are  more  slowly  restored. 

When  granulation  tissue  has  replaced  a  tissue  defect,  the  newly  formed 
blood-vessels  become  smaller  as  the  transformation  into  scar  tissue  takes  place. 
Collections  of  Ijonphoid  cells  may  persist  long  after  all  other  signs  of  the  in- 
flammatory reaction  have  disappeared,  and  are  best  explained  on  the  groimd  of 
hyperplastic  iTidimentary  lymph  nodes.  In  general,  the  restoration  of  the 
normal  vascular  conditions  depends  upon  the  duration  of  the  exciting  cause, 
the  amoimt  of  dead  tissue  and  exudate  to  be  disposed  of,  and  the  size  of  the 
defect  to  be  filled  in. 

Repair  of  the  Tissue  Defect. — This  is  accomplished  by  cell  proliferation 
leading  to  regeneration  or  repair,  according  to  the  nature  and  severity  of  the 
inflammatory  agent  and  the  character  of  the  tissue  involved.     When  only  single 


100  AMERICAN  PRACTICE   OF  SURGERY. 

cells  are  lost  or  the  organization  of  the  tissue  is  but  slightly  disturbed,  there  oc- 
curs in  the  majority  of  tissues  a  rapid  regeneration.  In  the  case  of  more  exten- 
sive lesions,  solution  of  continuity,  womids,  fractiires,  necrotic  inflammations, 
suppurations,  etc.,  there  is  first  formed  a  granulation  tissue,  which  later  becomes 
changed  to  scar  tissue.  Evidences  of  the  beginning  of  cell  proliferation  may  be 
seen  microscopically  as  early  as  eight  hours  after  the  injury,  but  the  process  is 
usually  not  well  established  until  after  twenty-four  hours  or  later.  The  estab- 
lishment of  cell  proliferation  is  dependent  upon  the  cessation  of  the  exciting  cause 
and  the  supply  in  abundance  of  the  materials  necessary  for  the  nutrition  of  the 
cells.  In  some  cases  the  phenomena  of  cell  proliferation  are  so  early  established 
and  form  so  marked  a  characteristic  of  the  inflammation  as  a  whole  that  it  may 
be  styled  a  productive  or  a  proliferating  inflanmiation.  All  factors  delaying  the 
progress  of  healing,  such  as  large  areas  of  necrosis,  large  masses  of  purulent  or 
fibrinous  exudate,  etc.,  give  to  the  inflammation  the  character  of  a  chronic 
process. 

10.  The  Healing  of  Inflammations. 

The  termination  of  the  mflammatory  reaction  is  knoTsm  as  healing.  The 
factors  constituting  the  resolution  of  the  inflammatory  process  and  upon  which 
the  healing  process  depends  have  been  considered  in  the  previous  section.  It 
is,  of  com-se,  evident,  according  to  the  standpoint  taken  in  this  article,  that  the 
entire  course  of  an  inflammation  is  directed  toward  a  common  end — that  of 
healing;  and  it  is,  therefore,  not  possible  to  separate  wholly  the  reparative 
factors  from  those  pm'ely  protective.  Wliile  the  enthe  inflammatory  reaction 
is,  broadly  viewed,  a  healing  process,  the  term  is  used  here  in  a  narrower  sense 
as  applying  to  the  final  phases  of  the  reaction. 

Healing  by  First  Intention  (per  primam  intentioiiem) . — In  the  case  of  an 
incised  Mountl  of  the  skin  whose  edges  are  glued  together  by  serum  or  blood  or 
are  held  together  by  sutures,  the  inflammatory  reaction,  in  the  absence  of  bac- 
terial infection,  is  slight.  Along  the  edges  of  the  wovmd  there  is  at  first  an 
abundant  exudation  of  serum  containing  more  or  less  blood;  this,  coagulating, 
holds  the  opposing  woimd  sm-faces  together.  At  the  same  time  there  occurs 
along  the  edges  of  the  wound  a  cellular  infiltration,  which  is  usually  not  very 
marked  and  reaches  its  maxhnum  in  a  few  days.  "When  sutures  have  been 
used  the  infiltration  is  usually  more  marked  about  these  than  along  the  edges 
of  the  womid.  By  the  end  of  twenty-four  hom-s  cell  proliferation  is  usually 
well  established  along  the  edges  of  the  womid.  By  the  third  or  fourth  day 
there  is  formed  a  granulation  tissue,  which  replaces  the  exudate  or  blood  clot 
between  the  woimd  surfaces  and  miites  them  together.  The  formative  tissue 
extends  also  on  both  sides  of  the  wound  for  some  little  distance  along  the  blood- 
and  lymph-vessels  into  the  neighboring  sound  tissue,  thus  blending  the  wound 
into  the  neighboring  tissue  in  such  a  way  that  the  edges  of  the  original  line  of 


INFLAMMATION. 


101 


incision  become  indistinct.  (See  Fig.  31.)  At  tlie  same  time  a  regeneration  of  the 
surface  epithelium  is  taking  place,  the  epithelial  cells  at  the  edge  of  the  wound 
pushing  over  the  wound  surface  and  dividing  to  form  many  layers.  The  forma- 
tive tissue  along  the  line  of  the  incision  gradually  becomes  less  rich  in  cells,  its 
blood-vessels  contract,  and  there  is  a  differentiation  of  fibrillar  in  its  intercellular 
substance.  Nevertheless,  for  a  long  time  afterward  the  scar  thus  formed  may 
show  evidences  of  proliferation  and  cellular  infiltration.  Finally,  the  place  of 
the  incision  can  no  longer  be  made  out,  as  the  line  of  scar  tissue  comes  to  re- 


■^v.'"^^^^ 


^3-_@#»5^'-f-Cr^ 


3  :M(m^j§^'T--'3^% 


Fig.  31. — Healing  of  Incised  Wound  of  Skin  united  by  Suture  (Flemming's  solution,  safranin).  Prep- 
aration made  on  the  sixth  day.  a,  Epidermis ;  b,  corium ;  c,  fibrinous  exudate,  in  part  hemorrhagic ; 
d,  newly  formed  epidermis,  containing  numerous  division  figures,  and  witli  plugs  of  epithelium  extend- 
ing into  the  underlying  exudate;  e,  division  figures  in  epithelium  at  a  distance  from  the  cut;  /,  pro- 
liferating embryonic  tissue,  developing  from  tlie  connective-tissue  spaces,  and  containing  cells  with 
nuclear  division  figures,  and  in  part  also  vessels  with  proliferating  walls;  g,  proliferating  embryonic 
tissue  with  leucocytes;  h,  focus  of  leucocy1:es  in  deepest  angle  of  wound;  i,  fibroblasts  lying  within  the 
exudate,  one  showing  a  nuclear  division  figure ;  k,  sebaceous  gland ;  I,  sweat  gland.  X  70.  (After 
Ziegler.) 

semble  the  neighboring  coimective  tissue.  The  time  necessary  for  the  complete 
healing  of  such  a  wound  depends  upon  its  size,  the  thickness  of  the  layer  of 
exudate  or  blood  clot  lying  between  the  opposing  woimd  surfaces,  and  the  pro- 
liferative capacity  of  the  tissue.  The  formation  of  granulation  tissue  along  the 
line  of  incision  is  not  always  imiform;  it  may  be  absent  in  places  or  vary  greatly 
in  amount  at  different  levels.  The  surface  epithelium  may  extend  across  the 
wound  before  the  formative  tissue  has  developed  below.  Occasionally  it  may 
become  hyperplastic.     Wlien  much  scar  tissue  is  formed,  its  later  contraction 


102 


AMERICAN   PRACTICE   OF  SURGERY. 


causes  a  flattening  or  even  depression  of  the  cutaneous  surface.     The  papiUary 
bodies  may  not  be  regenerated  and  a  smooth  scar  may  result.     (See  Fig.  32.) 

Healing  by  Second  Intention  {mr  seomdam  intentionem) . — In  the  case  of 
an  open  wound  of  the  skin  whose  edges  cannot  be  brought  together,  there  oc- 
curs, in  case  the  wound  does  not  become  infected,  a  serous  or  bloody  exudation 
followed  by  cell  proliferation  at  the  base  of  the  wound.  Within  twenty-four 
hours  the  base  of  the  wound  is  deep  red  in  color  and  more  or  less  swollen. 
It  is  covered  with  a  reddish-yellow  exudate.  After  twenty-four  hours  there 
begin  to  develop  over  the  base  of  the  wound  small  red  papules  of  formative 


..j^^<-^L/j( 


Fig.  32. — Cutaneous  Portion  of  a  Laparotomy  Cicatrix,  Sixteen  Days  after  the  Operation  (Mueller's 
fluid,  litematoxylin,  Van  Gieson's).  a,  Epithelium;  b,  corium;  c,  subcutaneous  fat  tissue;  d,  scar  in 
corium;  e,  new  epitlielial  covering ;/,  scar  in  fat  tissue.      X  38.      {After  Zieglcr.) 


tissue.  These  increase  in  number  and  become  confluent,  so  that  by  the  fourth 
or  fifth  day  the  entire  floor  of  the  wound  may  be  covered  by  a  granular  red 
surface,  over  which  lies  a  more  or  less  thick,  grayish,  gelatinous  layer  of  exu- 
date. This  exudate  is  very  rich  in  albumin  and  fibrinogen,  and  contains 
many  round  cells,  chiefly  of  the  polymorphonuclear  variety  {"pus  cells").  Many 
of  these  show  degenerating  nuclei. 

The  formative  tissue  {granulation  tissue)  at  the  base  of  the  woimd  con- 
sists of  fibroblasts,  newly  formed  capillary  loops,  and  leucocytes  embedded 
in  a  fluid  or  semifluid  intercellular  substance.  In  the  latter  there  is  soon 
developed  a  fibrillar  ground  substance.  Over  the  surface  of  the  granulation 
tissue  there  is  a  layer  of  exudate  rich  in  fibrin  and  containing  many  pus  cells. 


INFLAMMATION. 


103 


(See  Fig.  33.)  At  the  edges  of  the  wound  there  is  a  rapid  proliferation  of  the 
epithelium,  and  a  layer  of  newly  formed  epithelial  cells  pushes  in  from  the 
periphery  over  the  wound  granulations,  often  extending  deep  down  under- 
neath the  superficial  layer  of  exudate.  As  the  wound  becomes  covered  with 
epithelium  and  as  the  granulation  tissue  is  gradually  differentiated  into  fibrous 
connective  tissue,  the  proliferative  processes  gradually  come  to  a  standstill. 
The  scar  thus  formed  is  at  first  very  vascular  and  of  a  red  color.  It  is  often 
elevated  and  covered  with  hyperplastic  epithelium.  As  the  scar  tissue  con- 
tracts the  vessels  become  smaller  and  many  of  them  are  obliterated.  The  new 
tissue  also  loses  in  volume.  Ultimately  the  scar  becomes  pale,  smooth,  and 
often  depressed.  The  papillary  bodies 
are  either  not  regenerated  or  they  are 
reproduced  only  to  a  slight  degree.  For 
a  long  time  the  tissue  of  the  scar  is  rich 
in  cells,  but  these  gradually  become 
reduced  in  numbers  and  the  tissue  be- 
comes dense  and  hyaline,  showing  rela- 
tively few  cells.  New  elastic  fibres  may 
be  formed.  The  regeneration  of  the 
cutaneous  glands  depends  upon  the 
severity  of  the  original  injury.  If 
portions  of  the  glands  are  preserved, 
new  glands  may  be  formed  from  these. 

The  process  of  healing  by  second 
intention  is  the  same  in  the  case  of 
wounds  of  the  internal  organs  in 
which  the  defect  is  large  enough  to 
be  filled  in  with  granulation  tissue 
visible  to  the  naked  eye.  In  the  case 
of  surfaces  not  covered  with  epithe- 
lium, the  new  scar  tissue  is  covered 
with  endothelium  (mesothelium)  or  be- 
comes adherent  to  neighboring  struct- 
ures. In  the  case  of  infected  wounds 
and  in  ulcers  due  to  pathogenic  micro-organisms,  the  process  of  healing  is  essen- 
tially the  same,  although  more  prolonged.  In  the  case  of  large  defects  healed 
by  second  intention,  the  resulting  contraction  of  the  scar  tissue  may  lead  to 
marked  deformities  of  the  organ  involved. 

Healing  of  Abscesses. — In  the  case  of  small  abscesses  the  pus  may  be  quick- 
ly liquefied  and  absorbed,  and  the  defect  is  closed  up  by  granulation  tissue 
which  is  transformed  into  scar  tissue.  In  the  case  of  larger  abscesses  there  is 
formed  about  the  periphery  of  the  cavity  a  zone  of  granulation  tissue  known 


Fig  3o — Wound  Gran  il  t  n^  irom  an  Open 
Wound  \Mth  Fibrmopurulent  Co\ermg  (Muellers 
fluid,  ha?matoxylin).  a,  Granulation  tissue;  b, 
fihrinopurulent  layer;  c,  blood-vessels.  X  135. 
{After  Zicgler.) 


104  AMERICAN  PRACTICE  OF  SURGERY. 

as  the  abscess  membrane  {pyogenetic  membrane).  As  the  contents  of  the  cavity 
are  gradually  liquefied  and  absorbed,  the  zone  of  granulation  tissue  extends 
toward  the  centre  and  gradually  fills  up  the  defect.  Scar  tissue  is  then  formed 
and  the  process  of  healing  is  complete.  If  the  process  of  liquefaction  and  ab- 
sorption is  incomplete,  the  pus  may  become  inspissated  or  calcified. 

Healing  of  Ulcers.— Ulcers  heal  by  second  intention,  as  described  above. 

Healing  of  Empyemata.— Large  amounts  of  pus  may  be  absorbed  from  the 
body  cavities.  Wlien  the  process  of  absorption  is  slow  or  if  the  pus  is  inspis- 
sated, the  tissues  enclosing  the  pus  produce  formative  tissue  and  the  healing 
process  is  precisely  the  same  as  that  in  the  case  of  an  abscess.  Large  amounts 
of  granulation  tissue  may  be  formed  in  the  case  of  chronic  empyemata.  If  the 
process  is  incomplete  the  remains  of  the  pus  may  become  calcified. 

Healing  of  Fibrinous  Inflammations.— Upon  a  mucous  surface  fibrinous  exu- 
dates are  cast  ofi^  or  liquefied.  Only  rarely  (healing  diphtheritic  processes)  do 
they  become  organized.     In  the  case  of  the  pulmonary  air  spaces,  masses  of 


#'r.' 


-f* 


Fig.  34. — Scheme  of  the  Organization  of  a  Fibrinous  Exudate  on  Serous  Membrane.  1,  Cellular 
infiltration  beneath  the  fibrin;  2,  first  extension  of  fibroblastic  tissue  into  the  fibrin;  3,  replacement  of 
fibrin  by  fibroblastic  tissue;  4,  fibrin  nearly  wholly  replaced  by  vascular  formative  tissue;  5,  complete 
replacement  of  fibrin  and  beginning  contraction ;  6,  contraction  and  transformation  into  scar  tissue. 
{After  Ribbert.) 

coagulated  exudate  when  not  liquefied  and  absorbed  may  be  replaced  by  gran- 
ulation tissue,  which  fills  up  the  alveolar  spaces,  leading  to  an  induration  of  the 
lung  {fibroid  -pneumonia).  The  fibroblastic  proliferation  proceeds  either  from 
the  connective  tissue  of  the  septa  or  from  that  of  the  alveolar  walls. 

Upon  serous  surfaces  a  deposit  of  fibrin  usually  leads  quickly  to  proliferative 
processes,  so  that  as  early  as  the  fourth  day  fibroblasts  may  be  seen  extending 
up  into  the  fibrinous  layer.  This  is  soon  followed  by  a  growth  of  capillary 
loops,  and  the  fibrin  layer  is  gradually  replaced  by  a  vascular  granulation  tissue, 
which  later  becomes  changed  to  a  dense  hyaline  scar  tissue.  (See  Fig.  34.)  Re- 
mains of  the  fibrin  may  persist  in  the  new  tissue  for  a  long  time.  If  the  exudate 
was  limited  in  area  the  new  tissue  becomes  covered  with  endothelium  (mesothe- 
lium),  but  when  it  is  of  large  extent  the  opposing  serous  surfaces  usually  become 
united  by  the  process  of  organization  (adhesions).  Such  inflammations  are  usu- 
ally spoken  of  as  adhesive.  (See  Fig.  35.)  It  is  evident  that  the  character  of  the 
healing  process  is  dependent  upon  the  amount  of  the  fibrinous  exudate  and  the 


INFLAMMATION. 


105 


situation  and  relations  of  the  affected  serous  surface.  In  the  case  of  small  de- 
posits the  organization  of  the  fibrin  leads  to,  thickenings  of  the  serous  mem- 
brane. The  gluing  together  of  two  serous  surfaces  by  a  fibrinous  exudate  leads 
also  to  the  formation  of  adhe- 
sions. When  the  amount  of 
fibrin  is  small  and  the  two  sur- 
faces move  upon  each  other, 
stringy  adhesions  may  be 
formed.  Large  amounts  of  fibrin 
may  fail  of  absorption  and  be- 
come inspissated  or  "calcified. 

Healing  of  Thrombi. — Coag- 
ulated masses  in  the  blood-ves- 
sels are  replaced  by  connective 
tissue  in  the  same  maimer  as 
are  fibrinous  exudates  upon 
serous  surfaces.  There  is  a 
fibroblastic  proliferation  of  the 
cells  in  the  vessel  wall.  Fibro- 
blasts and  newly  formed  Capil-  Fig.  35.— Formation  of  Adhesions  between  the  Layers  of 
.  1  .         -I  j_    •     ,       l_^         the  Pericardium  in  Fibrinous  Pericarditis,   a,  Epicardium: 

lary    loops    extend    out    mtO    the    ^^  ^^^.^^^^  i^^^^.    ^_  ^,^^^^3  ti^^^,,  containing  remains 

thrombus,     which     is     gradually    of  fibrin;  d,  connecting  bridges  of  formative  tissue.      (^After 
,  ,     ,  ,  ,         Weichselbaum.) 

replaced   by   vascular  granula- 
tion tissue,  which  later  is  transformed  into  a  denser  fibrous  connective  tissue. 
The  vessel  lumen   may  be  obliterated  or  the  vessel  wall  may  present  local 
thickenings.     Failure  of  organization  may  be  followed  by  calcification  of  the 
thrombus. 

Healing  of  Necrotic  Areas.^Masses  of  necrotic  tissue  that  cannot  be  dis- 
posed of  by  sloughing  and  sequestration  are  replaced  by  formative  tissue  and 
scar  tissue,  in  the  same  manner  as  takes  place  in  the  case  of  fibrinous  exudates 
and  thrombi.    The  organization  begins  at  the  periphery  and  extends  toward  the 


Fig.  36. — Foreign-body  Giant  Cells  attached  to  Silk  Thread.     {After  Ribbert.) 

centre  of  the  dead  area.     Large  masses  may  become  encapsulated,  the  central 
necrotic  material  becoming  inspissated,  calcified,  or  liquefied. 

Healing  of  Foreign  Bodies. — In  the  case  of  bland  foreign  bodies  that  are 
easily  absorbed,  the  process  of  healing  takes  place  in  the  same  manner  as  in 
the  case  of  fibrinous  exudates  or  necrosed  tissue.     The  foreign  substance  is 


106  AMERICAN  PRACTICE  OF  SURGERY. 

liquefied  and  the  defect  replaced  by  scar  tissue.  Small  bodies  that  cannot  be 
liquefied  are  taken  up  by  phagocytes  and  in  the  course  of  time  are  gradually 
removed  from  the  body  (dust,  carbon,  tattoo,  etc.).  In  the  case  of  bodies  too 
large  to  be  taken  up  entire  by  phagocytes,  there  occurs  in  the  granulation  tissue 
developing  about  them  a  formation  of  large  multinuclear  giant  cells,  which  at- 
tach themselves  to  the  surface  of  the  foreign  body  and  cling  to  it  (foreign-body 
giant  celU.)  (See  Fig.  36.)  These  cells  resemble  the  physiological  osteoclasts.  If 
the  foreign  body  is  slowly  soluble  (catgut,  etc.)  these  cells  gradually  bring  about 
its  disintegration.  When  the  foreign  body  contains  crevices,  the  protoplasmic 
processes  of  the  giant  cells  extend  into  these  and  gradually  widen  them.  If  the 
foreign  substance  is  insoluble  (hairs,  silk,  silver  wire,  etc.),  the  giant  cells  cover- 
ing it  gradually  give  place  to  a  capsule  of  scar  tissue  (encapsidation).  In  the 
case  of  smooth  bodies  (glass,  etc.)  the  amount  of  granulation  tissue  formed 


A  B  C 

Fig.  37. — Anterior  Chamber  of  Rabbit's  Eye  after  Injection  of  Agar.  A,  Three  days  later.  Iris  be- 
low ;  above,  the  homogeneous  agar  containing  leucocytes  and  some  fibrin.  B,  eight  days  later;  large  for- 
mative cells  about  the  agar  mass.     C,  three  weeks  later;  spindle  cells  replacing  agar.      {After  Ribbert.) 


may  be  very  small.  Not  all  foreign  bodies  excite  the  production  of  giant  cells; 
hard  bodies  coming  from  without  the  body  favor  most  their  production,  but  ex- 
trinsic soft  bodies  may  also  cause  their  formation  in  large  numbers.  (See  Figs. 
37  and  38.)  They  are,  however,  frequently  seen  about  necrotic  tissue  (dead 
muscle  fibres).  The  giant  cells  arise  from  the  connective-tissue  cells  and  the 
endothelium.  Mitotic  division  of  the  nuclei  takes  place  without  division 
of  the  protoplasm.  While  many  of  the  giant  cells  appear  to  undergo  dis- 
integration, some  split  up  into  fibroblasts  and  take  part  in  the  production  of 
scar  tissue. 

The  leucocytes  also  play  an  important  role  in  the  reaction  against  foreign 
bodies.  They  usually  quickly  assemble  at  their  site,  take  them  up  when  pos- 
sible, penetrate  into  their  crevices,  and  aid  in  the  process  of  disintegration. 
Fibroblastic  proliferation  follows  or  is  associated  with  the  assemblage  of  leuco- 
cytes, many  of  the  fibroblasts  actuig  also  as  phagocytes. 


INFLAMMATION.  107 

11.  Sequel.e  of  Inflammations. 

The  sequels  of  inflammations  depend  upon"  the  nature  of  the  exciting  cause, 
the  location  of  the  tissue  involved,  its  character  and  condition,  the  severity  of 
the  process,  the  length  of  the  course,  and  the  nature  of  the  healing  process.  In 
a  general  way  the  most  important  sequelae  of  inflammation  are  those  dependent 
upon  cicatrization.  The  formation  of  scar  tissue  with  subsequent  contraction 
may  lead  to  extensive  atrophy  of  the  parenchyma  of  the  affected  organ.  The 
obliteration  of  serous  cavities  or  the  formation  of  adhesions  on  serous  mem- 
branes may  lead  to  serious  impairment  of  function.     The  constriction  of  the 


r,    0.   '• 


Fig.  38. — Subcutaneous  Injection   of   Agar.      Ten   weeks   after.      A,  Agar  mass  in   centre  of  large, 
multinucleated  giant  cell  showing  numerous  processes.      {After  Ribbert,) 

intestine  by  such  bands  of  inflammatory  adhesions  may  lead  to  fatal  results. 
The  contraction  of  scar  tissue  leads  also  to  surface  disfigurations  and  defor- 
mities. The  involvement  of  old  nerve  trunks  or  of  newly  formed  nerve  fibres  in 
the  scar  tissue  may  give  rise  to  an  "irritable  scar."  Through  the  organization 
of  fibrinous  exudate  upon  their  serous  surfaces  the  capsule  of  such  organs  as  the 
liver,  spleen,  etc.,  may  be  greatly  thickened.  This  thickening  of  the  capsule 
may  lead  to  a  further  secondary  atrophy  of  the  parenchyma.  The  obliteration 
of  blood-vessels  through  the  organization  of  thrombi  or  connective-tissue  prolif- 
eration of  their  walls  leads  likewise  to  secondary  parenchymatous  atrophy. 
Through  the  organization  of  exudates  lying  within  small  body  cavities,  as  the 
pulmonary  air  spaces,  induration  of  the  affected  organ  follows  and  the  spaces 
are  wholly  or  partly  obliterated.  The  contraction  of  the  scar  tissue  folloT\ang 
the  healing  of  ulcers  of  body  passages,  such  as  the  oesophagus,  stomach,  intes- 


108  AiMERICAN  PRACTICE  OF  SURGERY. 

tine,  etc.,  may  result  in  partial  or  complete  stenosis.     Inflammatory  atresias 
may  occur  (vagina). 

On  the  other  hand,  many  inflammatory  processes  lead  to  an  overproduction 
of  tissue.  Extensive  new  formation  of  bone  may  follow  chronic  inflanmiations 
of  the  periosteum  or  bone  marrow.  Connective-tissue  hyperplasias  of  great  ex- 
tent may  be  associated  with  the  presence  of  filaria  in  the  lymphatics  of  the 
scrotum  and  extremities  (elephantiasis).  Chronic  inflammations  of  the  skin  and 
mucous  membranes  may  be  foflowed  by  polypoid  or  wart-like  hyperplasias  of 
the  connective  tissue  and  epithelium  (condylomata).  Similar  hyperplasias  may 
be  seen  about  the  edge  of  chronic  ulcers  and  in  association  with  chronic  infec- 
tive processes.  Many  chronic  infective  inflammations  are  characterized  by  tu- 
mor-like formations  of  granulation  tissue  (syphilis,  tuberculosis,  leprosy,  etc.). 
These  are  usually  classed  under  the  head  of  infective  granulomata.  The  process 
of  regeneration  often  leads  to  an  overproduction  of  epithelial  structures,  as  hap- 
pens in  the  new  formation  of  bile  ducts  occurring  in  hepatic  cirrhosis. 

12.  Significance  of  the  Infl.uimatory  Process. 

Summing  up  the  features  of  the  inflammatory  reaction,  we  find  that  the 
process  as  a  whole  is  of  decided  advantage  to  the  organism.  Chemotaxis, 
phagocytosis,  increased  formation  of  lymph,  hypertemia,  emigration  of  white 
cells,  formation  of  extracellular  and  intracellular  bactericidal  substances,  pro- 
duction of  antitoxins,  formation  of  cell  barriers,  the  increased  temperature,  cell 
proliferation,  etc. — all  of  these  factors  in  the  process  can  be  interpreted  as  serv- 
ing for  the  protection  or  repair  of  the  organism.  Inflammation  may  then  be 
considered  a  body  fimction.  As  a  matter  of  fact,  practically  all  the  factors  of 
the  inflammatory  reaction  are  constantly  active  in  the  body.  Phagocytosis, 
chemotaxis,  Ij^mph  formation,  cellular  emigration,  cell  prohferation,  etc.,  are 
constantly  occurring  in  the  body,  but  become  manifested  as  inflammation  only 
when  occurring  in  a  greater  degree  than  under  ordinary  conditions.  Like  all 
other  body  functions,  that  of  inflammation  is  subject  to  disturbances  and  is 
often  very  imperfectly  carried  out.  Wlien  the  great  variety  of  factors  and  con- 
ditions influencing  it  is  considered,  there  need  be  no  wonder  at  the  fact  that  in 
the  struggle  for  protection  and  defence  the  inflammatory  function  as  a  whole 
may  appear  as  a  harmful  process  rather  than  as  a  preservative  one.  The  in- 
flammatory factors  work  more  or  less  blindly,  without  discrimination.  The 
inflammatory  reaction  cannot  adapt  itself  to  the  anatomical  and  fimctional 
peculiarities  of  different  organs  and  tissues.  Thus  an  inflammatory  reaction 
that  may  be  successful  from  the  standpoint  of  protection  in  other  parts  of  the 
body  may  lead  to  fatal  results  in  the  larynx  or  brain,  as  the  result  of  occlusion 
or  pressui'e.  Welch  speaks  of  the  "  excesses,  disorders,  and  failures  incident  to 
inflammation."    As  the  adaptation  of  the  animal  body  to  the  extrinsic  factors 


INFLAMMATION.  109 

influencing  it  is  an  imperfect  one,  so  is  the  local  reaction  limited  and  imperfect. 
Against  some  injurious  agents  the  organism  ■  is  able  to  produce  but  a  slight 
reaction.  The  serous  exudate  may  have  little  or  no  bactericidal  action.  The 
formation  of  antitoxin  may  be  limited  or  not  occur.  Positive  chemotaxis  may 
not  occur.  The  phagocytes,  instead  of  destroying,  may  be  destroyed  or  may 
transport  the  injurious  agent  (bacteria)  to  other  parts  of  the  body.  The  pour- 
ing out  of  an  exudate  into  the  pericardial  cavity  may  seriously  impair  the  effi- 
ciency of  the  heart.  Collections  of  exudate  in  the  pleural  cavity  cause  inter- 
ference with  both  respiratory  and  cardiac  functions.  Meningeal  exudates  cause 
cerebral  compression;  the  filling  up  of  the  pulmonary  air  spaces  with  exudates 
causes  respiratory  and  circulatory  embarrassment ;  inflammatory  processes  upon 
the  heart  valves  are  followed  often  by  stenosis  or  insufficiency,  etc.  The  con- 
traction of  scar  tissue  may  lead  to  severe  secondary  anatomical  changes  and 
functional  disturbances.  In  its  somewhat  blind  method  of  carrying  out  its 
protective  function,  the  inflammatory  reaction  creates  conditions  that  are  in 
themselves  harmful  or  dangerous.  In  the  attempt  to  overcome  the  primary 
injury,  the  creation  of  such  dangerous  conditions  is  at  times  unavoidable. 

\¥hile  such  injurious  effects  of  the  inflammatory  reaction  give  to  it,  when 
viewed  from  the  standpoint  of  the  clinician,  the  character  of  a  harmful  process 
demanding  surgical  intervention,  they  should  not  blind  him  to  the  essential 
biologic  facts.  Inflammation  is  an  exaggeration  of  normal  body  functions — a 
struggle  for  protection  and  self-preservation — becoming  manifest  as  the  reaction  to 
local  injury. 

13.  General  Indications  for  Treatment  of  Inflammation. 

While  taking  the  ground  that  the  inflammatory  reaction  is  but  an  exaggera- 
tion of  normal  body  fimctions  aimed  at  protection  and  repair,  the  necessity  for 
medical  and  surgical  intervention  is  not  denied.  On  the  contrary,  such  active 
intervention  becomes  more  clearly  indicated  as  the  limitations  and  imperfections 
of  the  protective  and  reparative  processes  are  recognized  and  the  better  under- 
stood. Having  gained  the  knowledge  that  inflammatory  processes  possess  a 
unity,  we  are  put  in  a  position  to  apply  logical  and  scientific  methods  of  treat- 
ment. And  it  is  to  this  knowledge  that  the  surgery  of  the  last  twenty  years 
owes  its  wonderful  advance  and  its  brilliant  victories.  The  discovery  of  the 
nature  of  the  most  common  and  important  etiological  factors  of  inflammation, 
and  the  knowledge  of  the  body's  means  of  defence  and  protection  against  these 
agents,  have  raised  the  treatment  of  inflammation  to  a  wonderful  plane  of  ad- 
vance. Surgery,  in  so  far  as  the  treatment  of  inflammation  is  concerned,  has, 
also,  become  protective  and  defensive.  Realizing  the  limitations  and  imperfec- 
tions of  the  body  function,  it  attempts  to  aid  its  protective  and  defensive  powers, 
to  limit  them  when  necessary,  and  to  avoid  the  "  excesses,  disorders,  and  failures  " 


no  MIERICAN  PRACTICE  OF  SURGERY, 

of  the  inflammatory  reaction.  Tlie  surgeon  supplies  tlie  additional  higher  func- 
tion of  judgment  and  discrimination  in  the  struggle  for  self-preservation.  He 
seeks  to  avoid  the  most  dangerous  etiological  agents,  to  prevent  simple  iniunes 
from  becoming  progressive  (infection),  to  limit  infection  when  it  has  occurred, 
to  aid  in  the  destruction  of  the  infective  agent,  to  control  the  body's  defensive 
powers  in  such  a  manner  that  damage  may  not  result  from  the  collection  of 
exudates,  to  shorten  the  course  of  the  reaction  by  the  removal  of  necrotic  tissue, 
exudates,  etc.,  and  to  further  the  com-se  of  repau-  by  the  coaptation  of  wound 
sin-faces,  removal  of  dead  tissue,  etc. 

In  addition,  the  smgeon  endeavors  to  support  the  organism  as  a  whole,  to 
keep  up  its  tone,  to  increase  its  resistance,  to  counteract  the  effect  of  general 
intoxications,  and  to  prevent  their  occur-rence.  By  means  of  bactericidal  sub- 
stances and  antitoxins  the  body  may  be  rendered  immune  to  certain  agents  that 
otherwise  would  excite  tissue  lesions  and  inflammatory  reaction.  The  surgeon 
may  supply  at  the  very  beginning,  before  serious  damag*  is  done,  those  ele- 
ments which  the  body  itself  can  produce  only  later  in  the  course  of  an  infection 
after  more  or  less  severe  local  injury  has  occm-red.  To  this  especial  branch  of 
treatment  we  look  for  greater  results. 

The  aid  which  the  surgeon  brings  to  the  body's  protective  forces  is,  however, 
still  imperfect.  The  course  of  many  infections  he  carniot  check,  his  operative 
procedures  may  often  do  more  harm  than  good,  the  bactericidal  substances 
which  he  uses  may  injure  the  tissues,  he  may  lower  the  local  resistance  instead 
of  raising  it  by  the  removal  of  exudates,  and  he  may  be  the  means  of  dissemina- 
tion of  the  infective  agent.  Such  imperfections  of  surgical  technique  we  look 
for  the  future  to  remove.  As  our  knowledge  of  the  biologic  facts  underlying 
the  inflammatory  reaction  increases,  so  will  the  methods  of  treatment  become 
perfected. 

II.   ACUTE     INFLAMMATION. 
1.  Acute  Simple  Inflammation. 

The  term  simple  inflammation  is  usually  employed  to  indicate  a  reaction  to 
trauma,  or  to  thermal  or  chemical  agents,  rather  than  one  resulting  from  infection 
(infective  inflammation).  The  term  "aseptic  injiammation"  is  sometimes  used 
as  a  synonym,  but  the  impropriety  of  this  is  evident.  Since  the  non-infective 
inflammations  are  usuall}^  non-exudative  in  character,  these  terms  have  also 
been  used  interchangeably.  Further,  since  the  non-infective  inflammations  usu- 
ally terminate  in  repair  or  regeneration,  they  are  often  spoken  of  as  formative 
inflammations.  But  inflammatorj^  reactions  of  exactly  the  same  clinical  charac- 
ter may  be  produced  by  bacteria  of  low  virulence,  the  colony  quickly  dying 
out,  so  that  the  process  is  non-exudative  and  non-progressive.  Bacterial  prod- 
ucts (toxins)  produce  similar  inflammatorj^  reactions.     For  that  reason  it  is  not 


INFLAMMATION.  Ill 

best  to  limit  the  term  to  non-infective  processes,  even  though  in  the  great  major- 
ity of  cases  simple  non-exudative  inflammations  are  not  the  result  of  infection. 
The  term  simple  inflammation  is,  therefore,  used  here  to  indicate  the  simple  re- 
action to  injury  when  it  is  characterized  not  by  exudative  processes  but  by 
formative. 

Simple  inflammations  may  be  caused  by  mechanical  injury  (friction,  blows, 
cuts,  wounds  of  any  nature,  surgical  operations,  etc.),  burns,  freezing,  corrosive 
poisons,  poisons  having  local  irritant  action,  electricity,  radioactivity,  anaemia, 
distin^bed  nutrition,  etc.  As  mentioned  above,  an  infection  with  germs  of  low 
virulence  that  quickly  die  out  may  produce  a  similar  clinical  and  histological 
pictm-e. 

The  symptoms  of  simple  inflammatory  reactions  are  the  five  cardinal  ones, 
more  or  less  modified  by  the  etiological  factor  and  the  location  of  the  injury. 
As  a  rule,  the  hyperemia  of  simple  inflammation  is  less  marked  than  in  the 
exudative  forms.  Since  the  various  forms  of  simple  traumatic  injury  are  the 
most  common  causes  of  simple  inflammation,  the  symptoms  usually  observed 
are,  first,  a  certain  degree  of  redness,  warmth,  and  swelling  about  the  injury, 
with  more  or  less  pain  or  soreness.  The  intensity  and  character  of  the  pain 
are  dependent  largely  upon  the  location  of  the  lesion.  Even  with  the  slightest 
wound  there  may  be  some  constitutional  symptoms,  notably  some  elevation  of 
temperature.  The  general  symptoms  are  usually  not  marked  unless  the  wound 
is  severe  or  covers  a  large  surface.  Symptoms  of  shock  may  be  associated  with 
those  directly  due  to  the  injury.  As  simple  inflammations  are  not  progressive 
and  do  not  spread,  the  symptoms  usually  reach  their  height  during  the  first 
two  or  three  days  and  then  gradually  disappear  as  the  process  undergoes 
resolution. 

The  microscopical  picture  is  that  of  a  simple  inflammatory  reaction  charac- 
terized chiefly  by  the  assemblage  of  wandering  cells  and  the  proliferation  of  the 
connective-tissue  cells  and  endothelium.  The  healing  of  wounds  may  take  place 
either  by  first  or  by  second  intention,  according  to  the  character  of  the  wound. 

Treatment. — The  treatment  of  simple  inflammations  is  directed  chiefly 
toward  the  prevention  of  infection  with  pyogenic  organisms,  to  minimize  the 
tissue  damage  as  much  as  possible,  and  to  hasten  resolution.  At  the  same  time 
attention  is  directed  toward  the  relief  of  the  symptoms. 

General  Measures. — Of  the  more  general  measures  to  be  carried  out  in  the 
treatment  of  simple  inflammations,  rest  is  of  the  greatest  importance.  If  there 
are  constitutional  symptoms  (fever)  the  patient  should  be  kept  in  bed;  other- 
wise, rest  of  the  affected  part  will  suffice.  Elevation  of  the  inflamed  part  often 
gives  marked  relief.  The  diet  is  of  great  importance,  particularly  after  surgical 
operations.  Nutritious  and  easily  digestible  food  should  be  supplied.  Milk 
diet,  either  as  fresh  or  sterilized  milk,  or  mixed  with  lime  water  or  potassium 
bicarbonate,  is  indicated  after  most  operations,  except  those  in  which  move- 


112  AMERICAN  PRACTICE  OF  SURGERY. 

ments  of  the  bowels  are  not  desired  for  several  days  (operations  upon  rectiim 
and  perineiun).  Light  nutritious  diet  may  be  substituted  for  the  milk  diet  or 
may  follow  it,  as  indicated.  Boiled  or  distilled  water  should  be  given  frequently 
in  small  quantities.  Nutrient  enemata  may  be  given  when  food  caimot  be 
borne  by  the  stomach.  Thirst  is  often  markedly  relieved  by  enemata  of  physio- 
logical salt  solution.  Several  days  after  the  operation  a  more  varied  solid  diet 
may  be  given.  Alcohol  should  be  used  with  caution.  It  may  be  of  service  as 
a  temporary  stimulant  when  the  pulse  shows  signs  of  cardiac  weakness.  During 
convalescence  the  lighter  alcoholic  drinks  may  be  used  as  tonics.  On  the  whole, 
the  general  treatment  is  directed  toward  the  support  and  building  up  of  the 
organism. 

Of  actual  drug  treatment  little  or  none  is  usually  indicated.  Antipyretics 
probably  do  actual  harm  and  are  contraindicated  in  surgical  cases.  Pvugatives 
are  to  be  used  with  judgment  and  discrimination  for  the  pm-pose  of  preventing 
intestinal  auto-intoxications.  They  are  also  occasionally  indicated  to  relieve 
the  tension  arising  from  collateral  congestions  and  to  excite  peristalsis.  Dia- 
phoretics and  diuretics  are  now  rarely  employed.  Pure  water  given  frequently 
in  small  quantities  serves  best  for  these  indications.  Wlien  the  pain  is  severe 
morphine  may  be  used  with  discrimination,  but  it  should  never  be  given  as  a 
matter  of  routine.  The  first  night  after  an  operation  may  often  be  passed  to 
greater  advantage  if  a  hypodermic  injection  of  morphine  is  given.  Under  other 
conditions  one-eighth  to  one-sixth  of  a  grain  by  the  mouth  usually  suffices.  If 
indicated  it  may  be  given  in  a  rectal  suppository.  On  the  whole,  it  is  better  to 
look  upon  the  use  of  morphine  as  a  last  resort  and  to  avoid  its  use  in  private 
practice  whenever  possible.  The  pain  and  restlessness  may  often  be  successfully 
combated  by  other  means.  Warm  baths,  hot  or  cold  pack,  potassium  bromide, 
sulfonal,  trional,  and  other  hypnotics  may  be  used.  Phenacetin  is  often  of 
service  in  relieving  neuralgic  pains.  Chloral  should  be  used  with  the  same  pre- 
cautions as  morphine.  The  period  of  convalescence  from  injury  or  operation 
demands  careful  hygienic  measures.  Massage,  directed  active  and  passive 
exercise,  proper  diet,  rest,  etc.,  should  be  systematically  carried  out  according 
to  the  needs  of  the  case.  Tonics  may  be  given  when  the  patient  is  anaemic  or 
shows  little  inclination  for  food. 

The  symptoms  of  shock  are  often  added  to  those  of  the  inflammatory  reac- 
tion. This  is  most  likely  to  be  the  case  after  injuries  to  the  abdominal  cavity, 
scrotum,  spinal  column,  etc.  Extensive  burns  of  the  skin,  lightning  or  elec- 
trical shocks,  corrosions,  etc.,  are  frequently  followed  by  shock.  Conditions  of 
nervous  excitement  predispose  to  shock,  while  narcosis  or  alcoholic  intoxication 
serves  to  inhibit  it.     The  treatment  will  be  considered  mider  the  proper  heading. 

Local  Treatment. — The  chief  consideration  in  the  local  treatment  of  in- 
juries is  the  prevention  of  infection.  The  general  principles  of  aseptic  surgery 
will  be  treated  in  another  chapter.     In  this  place  only  the  treatment  of  the 


INFLAMMATION.  113 

simple  inflammatory  reaction  following  the  proper  treatment  of  the  woimd  or 
injury  will  be  considered.  It  will  be  assimied  that  the  wound  or  part  has  been 
carefully  cleaned  and  made  aseptic,  hemorrhage  checked,  coaptation  secured, 
and  proper  dressings  applied.  Under  such  conditions  in  the  great  majority  of 
cases  no  especial  local  treatment  will  be  found  necessary.  Attention  to  the 
general  prmciples  given  above  are  usually  sufficient,  inasmuch  as  the  inflamma- 
tory process  quickly  reaches  its  height  and  passes  to  a  rapid  resolution.  Never- 
theless, there  are  certain  general  principles  of  local  treatment  which  may  often 
be  applied  with  the  greatest  benefit.  These  principles  all  aim  toward  the  relief 
of  tmpleasant  symptoms  and  to  assist  the  resolution  of  the  process. 

Rest  of  the  affected  part  is  one  of  the  most  important  factors  in  relieving  the 
pain,  reducing  the  amount  of  tissue  damage,  and  preventing  unnecessary  exu- 
dation and  swelling.  The  position  of  the  part  is  also  of  great  importance  in 
assisting  the  reaction.  As  a  rule,  elevation  of  tlie  injured  part  is  found  to  be 
of  advantage.  Strapping,  bandaging,  or  encasing  the  part  m  plaster-of-Paris 
dressings  may  be  necessary  to  secure  immovability.  In  the  case  of  fractures 
splints  are  used.  Functional  rest  of  the  injured  part  is  often  desirable  or  neces- 
sary, in  order  to  bring  about  resolution.  This  may  be  secured  in  various  ways, 
according  to  the  organ  affected. 

Cold  is  often  of  great  service  in  reducing  the  discomforts  of  the  inflammation. 
Applied  by  means  of  the  ice  bag  or  ice  coil,  through  which  a  constant  stream  of 
ice  water  is  kept  flowing,  it  often  greatly  reduces  the  pain  and  lessens  the  exu- 
dation and  swelling.  Its  use  is  contraindicated  when  the  vitality  of  the  part  is 
lowered  and  when  the  venous  stasis  is  marked.  When  the  temperature  of  the 
inflamed  area  is  not  much  increased,  its  color  cyanotic,  and  the  swelling  marked, 
the  application  of  cold  may  cause  actual  damage.  Gangrene  ma^'  follow  the 
over-zealous  use  of  the  ice  bag.  The  simple  application  of  cold  cloths  or  the 
immersion  of  the  affected  part  in  cold  water  often  has  a  marked  soothing  effect. 
Cold  water  allowed  to  drip  constantly  upon  the  bandage  or  dressings  may  be 
employed  for  the  same  purpose.  The  individual  conditions  of  the  case  are,  of 
coiu-se,  to  be  considered  in  the  employment  of  cold  according  to  any  one  of 
these  methods. 

Heat  is  also  an  important  factor  in  the  treatment  of  simple  inflammatory 
reactions.  It  may  be  applied  by  the  use  of  hot  poultices  and  dressings,  hot  dry 
cloths,  hot  air,  hot  sand,  irons,  bricks,  etc.,  hot-water  bags,  bottles,  etc.,  hot- 
water  coil,  hot-water  bath,  etc.  Many  surgeons  make  a  marked  distinction  be- 
tween the  use  of  dry  heat  and  the  employment  of  moist  heat.  The  degree  of 
warmth  is  also  of  importance,  as  the  action  of  heat  varies  according  to  its  degree. 
A  moderate  degree  of  heat,  as  in  the  case  of  a  warm  poultice,  causes  a  dilatation 
of  the  superficial  vessels,  increases  the  hyperemia,  and  thereby  is  of  direct  aid 
to  the  inflammatory  reaction  in  increasing  its  protective  factors,  in  flushing  the 
tissue,  and  in  increasing  the  exudate.    A  greater  degree  of  heat  may  contract  the 


114  AMERICAN  PRACTICE  OF  SURGERY. 

superficial  arterioles  and  lessen  the  hyperaemia.  It  is,  therefore,  usually  applied 
at  the  beginning  of  an  inflammation.  Its  utility  is  doubtful  and  the  inflam- 
matory reaction  may  be  delayed  as  the  result  of  its  application.  As  a  rule,  the 
use  of  moderate  moist  heat  (poultices,  fomentations,  etc.)  is  often  of  service  in 
the  later  stages  of  inflammation,  in  many  cases  undoubtedly  hastening  the  proc- 
ess by  promoting  exudation  and  causing  an  earlier  resolution.  Such  effects  are 
seen  especially  in  local  processes  that  "come  to  a  head"  or  "point"  (suppura- 
tive inflammation).  As  a  matter  of  fact,  the  choice  between  dry  or  moist  cold 
and  dry  or  moist  heat  probably  lies  wholly  in  the  line  of  convenience,  ex- 
pediency, and  comfort.  Cases  are,  therefore,  to  be  treated  individually,  so 
far  as  the  employment  of  these  agents  is  concerned. 

Ligature  of  arteries  supplying  inflamed  parts  has  been  recommended  as  a 
means  of  checking  inflammatory  processes  in  certain  parts  of  the  body.  Such 
a  procedure  is  based  upon  an  incorrect  conception  of  the  inflammatory  reaction 
and  must  be  regarded  as  a  harmful  and  dangerous  method  of  treatment.  It 
belongs  to  the  old  antiphlogistic  conception  of  the  process  ("starving  of  the 
inflammation"). 

Bleeding. — Venesection  is  now  rarely  employed.  In  certain  cases,  where 
there  is  a  general  venous  stasis,  its  employment  may  be  of  value.  Local  bleed- 
ing is  often  resorted  to  when  the  local  stasis  is  extreme,  the  part  cyanotic,  and 
the  temperature  lowered.  This  is  particularly  the  case  in  severe  injuries  to  the 
extremities  after  fractures  of  bones  and  rupture  of  large  vessels.  The  stasis 
may  be  so  extreme  that  fresh  arterial  blood  cannot  gain  access  to  the  part,  and 
there  may  be  serious  danger  of  gangrene.  Free  incisions  may  relieve  the  venous 
stasis,  allow  the  arterial  blood  to  flow  mto  the  part,  and  so  permit  of  the  col- 
lateral circulation  being  established.  The  incisions  should  be  long  and  deep 
enough  to  relieve  the  tension.  Superficial  scarification  rarely  succeeds  in  ac- 
complishing this.  The  incisions  should,  therefore,  be  deep  enough  to  reach 
through  the  subcutaneous  tissues  into  the  muscle.  Alternating  short  incisions 
or  deep  punctures  may  be  employed.  The  contents  of  hsematomata  should  be 
removed.  All  of  these  procedures  should,  of  course,  be  carried  out  according 
to  the  i^rinciples  of  aseptic  surgery.  In  regions  where  it  is  not  desirable  to  make 
incisions  leeches  might  often  be  employed  to  advantage,  but  they  are  rarely 
made  use  of  at  the  present  time.  The  modern  tendency  is  to  interfere  less  and 
less  with  the  inflammatory  reaction  and  to  devote  the  chief  attention  to  the 
maintenance  of  asepsis.  For  that  reason  local  incisions,  like  venesection,  are 
now  rarely  performed. 

The  use  of  counter-irritants,  at  least  in  the  case  of  acute  inflammations,  has 
also  nearly  become  obsolete.  Wlien  resolution  is  delayed  and  there  is  danger 
of  the  process  becoming  chronic,  counter-irritation  may  often  be  used  to  great 
advantage.  Mustard  plasters,  tincture  of  iodine,  fly  blisters,  cutaneous  irritants 
of  various  kinds,  and  the  actual  cautery  may  be  employed.     Counter-irritation 


INFLAMMATION.  115 

acts  by  the  production  of  an  active  hypera;mia  and  the  estabUshment  of  a 
fresher  inflammatory  reaction,  which  may  aid.  in  advancing  the  older  sluggish 
process  toward  resolution.  Exudates  may  in  this  way  be  more  quickly  ab- 
sorbed, the  part  is  flushed  out  by  the  increased  circulation  through  it,  and  the 
processes  of  repair  stimulated. 

Compression  may  often  be  used  to  advantage  to  diminish  the  swelling  and 
exudation,  and  thus  to  hasten  resolution  and  shorten  the  period  of  convales- 
cence. It  is  of  particular  value  in  the  case  of  inflamed  joints.  It  may  be  applied 
by  means  of  splints,  casts,  elastic  stockings,  bandages,  etc.,  and  may  be  made 
use  of  both  in  the  early  and  in  the  late  stages  of  the  inflammation.  It  should 
not  be  employed  when  the  vitality  of  the  tissues  is  low  or  when  the  circulation 
is  greatly  disturbed.  The  pressure  should  be  applied  equally  and  should  not 
cause  pain.  The  rest  given  to  the  part  is  probably  the  chief  factor  in  the  favor- 
able results  often  obtained,  although  there  can  be  no  doubt  that  the  absorption 
of  exudates  may  be  hastened  by  pressure.  Old  chronic  swellings,  in  particular, 
are  favorably  affected  by  continuous  pressure  and  often  are  made  to  disappear 
quickly  by  this  means. 

The  local  use  of  drugs  supposed  to  have  specific  action  on  the  inflammatory 
process  has  been  practically  discontinued.  With  the  exception  of  bactericidal 
substances  or  of  substances  supposed  to  exert  such  action,  local  applications 
are  now  rarely  made.  The  best  surgical  methods  discard  such  treatment  en- 
tirely. Aseptic  methods  are  better  than  antiseptic;  the  agents  used  for  bac- 
tericidal purposes  may  in  themselves  cause  damage  to  the  tissues.  In  the  case 
of  wounds  and  in  operations  upon  parts  already  infected,  the  use  of  such  anti- 
bacterial agents  may  be  necessary,  and  in  such  cases  those  substances  should  be 
employed  that  cause  least  tissue  injury  or  irritation.  Aseptic  cleansing  should 
first  be  employed  to  the  fullest  extent  possible,  and,  when  thoroughly  carried 
out,  it  should  suffice.  In  the  case  of  wounds  containing  foreign  substances,  dirt, 
etc.,  pure  carbolic  acid,  in  connection  with  alcohol,  mercuric-chlorid  solutions, 
etc.,  may  be  used  as  indicated.  In  the  case  of  burns,  local  applications  may  be 
employed  for  the  purpose  of  relieving  the  pain  (antiseptic  dusting  powders, 
etc.).  The  astringent  solutions  so  popular  as  local  applications  to  inflamed 
parts  have  little  or  no  value. 

The  resolution  of  acute  simple  inflammations  is  brought  about  by  means  of 
simple  cell  reproduction,  healing  by  first  intention,  or  by  second  intention,  as 
described  in  detail  in  previous  paragraphs. 

2.  Acute  Serous  Inflammations. 

When  the  inflammatory  exudate  consists  chiefly  of  fluid  containing  but  few 
cellular  elements,  it  is  termed  serous  and  the  inflammation  is  spoken  of  as  a 
serous  inflammation.     The  collection  of  the  fluid  exudate  in  the  tissue  spaces 


116  AMERICAN  PRACTICE  OF  SURGERY. 

gives  rise  to  an  inflammatory  wdema.  Upon  free  surfaces  the  serous  inflamma- 
tions manifest  themselves  as  serous  catarrhs.  Since  there  is  usually  a  marked 
mucoid  degeneration  of  the  epithelium  of  such  an  inflamed  membrane,  the  exu- 
date comes  to  contain  a  large  amount  of  mucus  {mucous  catarrh.)  (See  Fig.  39.) 
At  times  there  is  also  a  marked  desquamation  of  the  surface  epithelium  (des- 
quamative catarrh).  The  presence  of  leucocytes  in  the  exudate  may  give  it  the 
character  of  a  seropurulent  catarrh;  when  fibrin  is  present,  the  exudate  may  be 
classed  as  serofibrinous.  Collections  of  serous  exudate  in  the  body  cavities  as 
the  result  of  inflammations  of  the  serous  membranes  are  spoken  of  as  serous  effu- 
sions. Small,  circumscribed  collections  of  serous  exudate  beneath  the  horny 
layer  of  the  epidermis,  with  the  liquefaction  of  the  lower  layers  of  the  epithe- 


^  M> 


!  J 

Fig.  39. — Mucoub  Catarrh  of  a  Bronchus  (Mueller'a  fluid,  amlmc-bron  n;  a,  Cihated  epithelium :  a, , 
deeper  cell  la\ers,  b,  goblet  cells,  c,  cells  sho^nng  marked  mucous  degeneration,  c,  mucoid  cells  with 
mucoid  nuclei;  d,  desquamated  mucoid  cells;  «,  desquamated  ciliated  cells;  /,  layers  of  drops  of  mucus; 
/i,  layer  consisting  of  thready  mucus  and  pus  corpuscles;  g,  duct  of  mucous  gland  filled  with  mucus  and 
cells;  h,  desquamated  epithelium  of  the  excretory  duct;  i,  intact  epithelium  of  the  duct;  k,  swollen 
hyaline  basement  membrane;  I,  connective  tissue  of  the  mucosa,  infiltrated  with  cells  in  part;  m,  dilated 
blood-vessels ;  n,  mucous  gland  filled  with  mucus ;  7ii,  lobule  of  mucous  gland  mthout  mucus ;  o,  wander- 
ing cells  in  epithehum;  p,  cellular  infiltration  of  the  connective  tissue  of  the  mucous  glands.  X  110. 
{After  Ziegler.) 

Hum,  give  rise  to  vesicles  and  blisters.     (See  Fig.  40.)      Larger  ones  are  termed 
bidke  and  blebs. 

Serous  inflammations  occur  most  frequently  upon  the  mucous  and  serous 
membranes.  They  may  be  caused  by  thermal,  chemical,  and  infective  agents. 
The  pyogenic  cocci,  the  diplococcus  of  pneumonia,  the  colon  bacillus,  influenza 
bacillus,  typhoid  bacillus,  bacillus  of  tuberculosis,  etc.,  may  produce  serous, 
seropurulent,  or  serofibrinous  inflammations.  Inflammatorj^  oedema  may  be 
caused  by  the  anthrax  bacillus,  the  colon  bacillus,  the  gas-forming  bacillus,  etc. 
The  clinical  picture  of  a  malignant  cedema  may  result.     Localized  inflammatory 


INFLAMMATION.  117 

ccdemas  are  also  produced  by  certain  drugs,  irritant  poisons,  bites  of  insects, 
stings,  etc.  Vesicles,  blebs,  bullae,  and  blisters. may  be  produced  by  burns,  cor- 
rosive poisons,  chemical  irritants,  friction,  and  many  forms  of  infection.  The 
majority  of  the  serous  inflammations  fall  into  the  province  of  general  medicine 
rather  than  into  that  of  surgery.  The  serous  catarrhs  are  rarely  treated  by  the 
surgeon.  On  the  other  hand,  the  treatment  of  blisters,  blebs,  serous  effusions, 
and  inflammatory  oedemas  is  chiefly  surgical. 

The  symptoms  of  serous  inflammations  are  those  of  inflammation  in  general. 
Since  they  are  usually  of  bacterial  origin,  the  general  symptoms  are  more  severe 
than  in  the  case  of  a  simple  inflammation.  The  general  picture  of  an  infective 
process  is  presented,  the  condition  running  a  more  or  less  definite  course.  Fever 
and  the  general  constitutional  intoxication  are  more  or  less  pronounced.     The 


Fig.  40. — Section  through  the  Border  of  a  Blister  Caused  by  a  Burn  (alcohol,  carmine),  a,  Horny 
layer;  b,  retc  Malpighii:  c,  normal  papillae;  d,  swollen  cells,  some  of  whose  nuclei  are  still  visible,  though 
pale,  wliile  others  have  been  destroyed;  e,  interpapillar}'  epithelial  cells,  the  deeper  ones  intact,  those  of 
the  upper  layers  are  drawn  oiit  longitudinally  and  in  part  are  swollen  and  have  lost  their  nuclei;  /,  total 
liquefaction  of  the  cells;  g,  interpapillary  cells,  without  nuclei,  swollen  and  raised  from  the  cutis;  ft, 
total  degeneration  of  interpapillary  cells  which  have  been  raised  from  the  cutis ;  k,  coagulated  exudate 
(fibrin)  lying  beneath  the  uplifted  epithelium;  i,  flattened  papillse  infiltrated  with  cells.  X  150. 
(After  Ziegler.) 

general  principles  of  treatment  of  inflammation  apply  here,  while  treatment  is 
also  directed  against  the  etiological  agent  and  the  extension  of  the  process. 
Such  general  treatment  usually  lies  outside  the  surgeon's  field,  and  he  is  called 
upon  to  treat  the  purely  surgical  features  of  the  case,  such  as  the  serous  effusion 
or  the  blister,  bleb,  or  bulla. 

Treatment  of  Blisters. — Blisters  or  blebs  when  tense  should  be  evacuated 
under  aseptic  precautions,  but  the  epidermis  should  not  be  removed.  The  part 
may  then  be  dressed  with  an  antiseptic  dusting  powder  or  ointment,  or  dry 
antiseptic  dressings  may  be  applied. 

Treatment  of  Effusions. — Serous  effusions  may  coUect  in  the  pleural,  peri- 
cardial and  peritoneal  cavities,  the  meningeal  spaces,  and  in  joints,  tendon 


118  AMERICAN  PRACTICE  OF  SURGERY. 

sheaths,  bursEe,  etc.  The  amount  of  fluid  may  be  so  great  as  to  cause  serious 
pressure  symptoms.  The  cardiac  and  respiratory  functions  may  be  seriously 
embarrassed  by  serous  effusions  in  the  pleural  or  pericardial  sacs.  Fatal  results 
may  be  brought  about  by  the  increased  pressure  upon  the  brain  or  cord  from 
the  accumulation  of  serous  exudate  in  the  intermeningeal  spaces.  The  move- 
ments of  the  joints  may  be  seriously  interfered  with  as  the  result  of  serous  in- 
flammations of  the  synovial  membranes.  The  relief  of  pressure  symptoms, 
therefore,  becomes  the  most  important  indication  so  far  as  the  surgical  treat- 
ment of  these  conditions  is  concerned.  It  is  a  waste  of  time  to  attempt  this  by 
means  of  counter-irritation,  attempts  at  specific  treatment,  methods  of  absorp- 
tion, etc.  Thoracentesis,  lumbar  puncture,  aspiration  of  the  joint  cavity,  etc., 
carried  out  according  to  the  principles  of  aseptic  surgery,  yield  the  most  certain, 
safe,  and  satisfactory  results.  Acute  inflammations  are  thus  kept  from  becom- 
ing chi-onic,  and  the  secondary  changes  in  organs  from  pressure  are  avoided. 
When  carefully  carried  out,  aspiration  is  practically  without  danger.  In  the 
case  of  large  effusions,  it  is  usually  best  to  remove  part  of  the  fluid  at  one  sitting 
and  the  remainder  at  another.  The  after-treatment  is  wholly  medical,  unless 
secondary  infection  should  occur. 

3.  Acute  Fibrinous  Inflammations. 

When  the  fluid  exudate  contains  a  large  amount  of  fibrin,  the  inflammation 
is  spoken  of  as  fibrinous,  and  the  exudate  is  classed  as  fihrinoiis  or  serofibrinous, 
as  the  case  may  be.  Frequently  the  exudate  may  consist  almost  wholly  of  a 
thick  mass  of  fibrin,  which  is  deposited  over  the  surface  of  the  affected  part 
(croupous  or  membranous  infiammation) .  Such  inflammations  occur  chiefly 
upon  the  mucous  membranes,  serous  surfaces,  and  in  the  limgs,  but  fibrinous 
exudates  may  also  be  formed  in  tissue  spaces  of  certain  organs  (lymph  nodes). 
Fibrinous  exudates  occurring  upon  mucous  membranes  are  often  associated  with 
a  necrosis  of  the  superficial  epithelium  {diphtheritic  inflammations).  The  causes 
of  fibrinous  inflammations  are  chiefly  infective  agents — the  pyogenic  cocci,  par- 
ticularly the  streptococcus;  also  the  Diplococcus  pneumonite,  the  Bacillus  diph- 
thericp,  etc.  The  streptococcus  and  the  diplococcus  give  rise  chiefly  to  croupous 
inflammations  of  the  lungs  and  pleura,  while  the  bacillus  of  diphtheria  causes 
diphtheritic  processes  in  the  upper  respiratory  tract.  The  streptococcus  also 
causes  diphtheritic  inflammations  in  the  respiratory  tract,  genito-urinary  tract, 
and  elsewhere.  The  irritant  gases,  inhalations  of  hot  air  or  flame,  and  the  cor- 
rosive poisons  are  also  capable  of  producing  fibrinous  inflammations,  chiefly  of 
the  diphtheritic  type. 

Upon  the  mucous  membranes  the  fibrinous  exudate  may  appear  as  a  whitish 
layer  or  patch,  or  it  may  foi-m  a  dense  grayish  membrane.  The  exudation  may 
begin  beneath  the  epithelium,  pushing  up  the  latter,  which  may  degenerate  or 


INFLAMMATION.  119 

become  necrotic.  The  surface  is  then  covered  with  a  grayish  membrane  infil- 
trated with  leucocytes  and  containing  the  remains  of  the  necrotic  epithelium. 
In  other  cases  the  exudate  follows  the  desquamation  of  the  fibrin.  Surfaces  still 
covered  with  epithelium  ma}^  become  covered  with  a  fibrinous  exudate  from 
exudation  occurring  through  neighboring  denuded  parts.  Successive  exudations 
may  give  rise  to  layers  of  fibrin  pushed  up  from  below.  Crystal-like  forms  of 
fibrin  may  be  found,  usually  having  a  leucocyte  or  a  red  blood  cell  as  a  centre. 
The  fibrin  itself  is  usually  reticular  or  arranged  in  coarse  strands  lying  parallel 
with  the  surface,  more  rarely  perpendicular  to  it.  A  distinct  stratification  is 
often  seen.  The  connective  tissue  below  is  hyperamic,  infiltrated  with  wander- 
ing cells,  and  shows  an  inflammatory  oedema  of  more  or  less  marked  degree. 
In  the  tissue  spaces  small  threads  of  fibrin  may  be  found,  while  the  dilated 
lymph  spaces  ma)'  show  a  thick  network  of  fibrin  threads.  In  the  diphtheritic 
process  the  fibrin  threads  may  be  found  lying  between  the  necrotic  epithelial 
cells.     (See  Fig.  41.) 

Upon  the  serous  surfaces  the  fibrinous  exudate  may  appear  to  the  naked  eye 
as  a  delicate  film  or  in  the  form  of  small  granules  giving  the  surface  a  rough  or 
granular  appearance,  or  there  maj'  be  formed  thick  j-ellowish  or  yellowish-red 
deposits,  which  often  give  to  the  surface  a  felted  or  villous  appearance  {cor  vil- 
lositm).  Microscopically,  the  fibrinous  deposit  may  be  granular  or  thready,  or 
even  appear  in  dense  hyaline  masses  or  stratified  bands.  The  endothelium  is 
usually  desquamated  in  whole  or  in  part  or  is  necrotic.  The  connective  tissue 
is  more  or  less  infiltrated  with  leucocytes,  the  blood-vessels  are  congested,  and 
the  tissue  spaces  filled  with  fluid  containing  fibrin  threads.  Numerous  leucocytes 
may  be  present,  giving  the  exudate  a  fibrinopurulent  character.  The  villous 
character  so  often  seen  upon  the  pericardium  and  pleura  is  due  to  the  gluing 
together  of  the  opposing  surfaces  by  the  sticky  fibrin  and  the  motion  of  the  two 
layers  drawing  the  fibrin  out  into  strings,  adhesions,  or  into  villous  projections. 

In  the  lungs  fibrinous  inflammations  are  characterized  b)'  the  filling  up  of 
the  alveolar  spaces  by  a  reticular  network  of  fibrin,  enclosing  in  its  spaces  leu- 
cocytes, red  blood  cells,  and  desquamated  alveolar  epithelium.  Fibrinous  exu- 
dations are  also  found  in  the  kidney  tubules,  the  bladder  mucosa,  endometrium, 
etc.  In  the  lymph  nodes  and  spleen  fibrinous  exudates  may  appear  in  the 
lymph  sinuses  of  the  former  and  the  follicles  of  the  latter. 

As  a  rule,  the  fibrinous  inflammations  are  much  more  severe  than  the  serous 
ones,  the  general  symptoms  are  more  marked,  and  the  symptoms  of  intoxication 
become  of  paramount  importance.  In  the  respiratory  tract  the  disturbance  of 
respiration  becomes  a  feature  of  great  importance.  Diphtheritic  inflammations 
of  the  upper  air  passages  may  result  fatally  from  the  stenosis  caused  by  the 
formation  of  the  membrane  upon  the  mucous  surface  of  the  larynx,  trachea, 
etc.  Croupous  inflammations  of  the  lungs  usually  involve  an  entire  lobe.  There 
is,  in  consequence,  embarrassment  of  respiration  and  insufficiency  of  the  right 


120  AMERICAN  PRACTICE  OF  SURGERY. 

heart.  In  the  case  of  fibrinous  inflammation  of  the  serous  surfaces  the  symp- 
toms are  similar  to  those  caused  by  serous  effusions  (pressure  symptoms).  The 
presence  of  the  fibrin  delays  absorption,  and  resolution  and  healing  are  there- 
fore retarded.  The  fibrin  itself  acts  as  a  foreign  substance  or  as  dead  material, 
and  excites  quickly  the  process  of  organization.  Thickenings  and  adhesions 
consequently  usually  follow  fibrinous  inflammations.    Indm-ation  of  the  lung 


€5* 


Fig.  41. — Sect  on  from  an  Inflamed  L\ulaCo\ered  with  a  Stratified  Fibr  nou  Membrane,  from  a  case 
of  diphtheritic  croup  of  the  phalangeal  organs  ("Mueller  bflmd  hsematoxjlm  eosm)  a  Surface  layer  of 
eoagulum,  consisting  of  epithelial  plates  and  fibrm  and  containing  numerous  colomes  of  cocci;  6,  second 
layer  of  eoagulum,  consisting  of  fine-meshed  fibrin  network  enclosing  leucocytes;  c,  third  la3'er  of  eoagu- 
lum. King  upon  the  connective  tissue,  and  consisting  of  a  \\ade-meshed  reticulum  of  fibrin  enclosing 
leucocytes;  d,  connective  tissue  infiltrated  witli  cells;  e,  infiltrated  boundary'  layer  of  the  connective 
tissue  of  the  mucous  membrane;  /,  heaps  of  red  blood  cells;  g,  widely  dilated  blood-vessels;  /i,  dilated 
lympii-vessels  tilled  with  fluid,  fibrin,  and  leucocytes ;  r,  duct  of  a  mucous  gland  distended  with  secretion; 
k,  transverse  section  of  a  gland;  I,  fibrin  reticulum  in  the  superficial  layer  of  connective  tissue.  X  45. 
(After  Ziegler.) 

may  follow  croupous  pneumonia.  Diphtheritic  inflammations  of  the  bladder, 
uterus,  intestines,  etc.,  are  of  importance  to  the  surgeon,  because  they  often 
follow  surgical  operations  upon  these  organs.  The  prognosis  in  such  cases  is 
always  grave.     The  streptococcus  is  the  most  common  infecting  agent. 

The  majority  of  fibrinous  inflammations  fall  within  the  province  of  general 


INFLAMMATION.  121 

medicine  ratlier  than  in  that  of  surgery.  Although  often  associated  with  or 
arising  chrectly  from  surgical  conditions,  the  treatment  in  the  majority  of  cases 
is  usually  purely  medical.  Obstruction  of  the  respiratory  passages  by  croupous 
or  diphtheritic  membranes  may  necessitate  surgical  operations,  such  as  trache- 
otomy or  lar3Tigotomy.  Fibrinous  inflammations  of  the  serous  membranes  in 
the  great  majority  of  cases  demand  aspiration  and  removal  of  the  accompanying 
fluid.  The  peritoneal  cavity  may  be  opened  in  the  case  of  fibrinous  peritonitis 
and  the  exudate  washed  out  by  sterile  physiological  salt  solution.  The  forma- 
tion of  peritoneal  adhesions  and  bands  maj^  necessitate  surgical  intervention 
because  of  secondary  complications.  In  fibrinous  arthritis  the  synovial  cavity 
may  be  aspirated  and  the  exudate  withdrawn  or  washed  out.  In  all  cases  of 
acute  fibrinous  inflammation  the  condition  of  the  patient's  kidneys  should  be 
carefully  ascertained.  Acute  degenerative  nephritis  often  brings  the  case  to  a 
speedy  end. 

4.  Acute  Purulent  Inflajimations. 

When  the  inflammatory  reaction  is  characterized  chiefly  by  a  leucocytic  exu- 
date, the  inflammation  is  styled  purulent.  If  the  leucocyte  mfiltration  is  not  so 
marked  as  to  be  evident  macroscopically  and  is  unaccompanied  by  liquefaction 
of  the  affected  area,  it  is  usually  spoken  of  as  a  small-celled  infiltration.  When 
the  leucocytes  are  so  numerous  as  to  give  to  the  tissues  a  white,  grayish,  or 
creamy  color,  the  infiltration  is  styled  purulent.  Such  an  exudate  poured  forth 
upon  a  free  surface  gives  rise  to  a  white  or  creamy,  cloudy  fluid  called  pus,  and 
the  inflammation  is  designated  a  purulent  catarrh.  (See  Fig.  42.)  A  persistent 
and  marked  catarrh  of  this  nature  is  often  called  a  blennorrhcea.  Collections 
of  purulent  exudate  within  the  body  cavities  are  known  as  purulent  effusions  or 
empyeinata.  A  purulent  vesicle — that  is,  a  collection  of  pus  beneath  the  horny 
layer  of  the  epidermis — is  known  as  a  pustule.  Larger  collections  are  called 
purulent  blebs  and  bullce. 

The  collection  of  large  numbers  of  leucocytes  within  the  tissue  spaces  is  usu- 
ally followed  by  a  liquefaction  and  dissolution  of  the  affected  area.  This  process 
is  termed  suppuration,  and  the  resulting  cavity  filled  with  leucocytes  and  tissue 
debris  is  an  abscess.  The  contents  of  the  cavity  are  also  designated  as  pus. 
When  the  suppurative  process  occurs  upon  the  surface  of  the  skin  or  mucous 
membranes,  there  is  a  superficial  loss  of  substance  giving  rise  to  an  ulcer.  The 
process  of  suppiiration,  when  extending  through  the  tissues,  often  gives  rise  to 
duct-like  tracts  known  as  fistulas  or  sinuses. 

The  inflammatory  exudate  often  assumes  the  character  of  a  seropurulent  in- 
flammation when  the  fluid  portion  is  abundant.  The  infiltration  of  the  tissues 
by  such  an  exudate  gives  rise  to  a  pitrulerit  aclenia.  (See  Fig.  43.)  Purulent  and 
seropurulent  inflammations,  when  rapidly  involving  large  areas,  particularly  of 
the  subcutaneous  or  subserous  tissues,  are  designated  as  phlegmons  or  phlegmo- 


122 


AMERIC.l^'  PRACTICE  OF  SURGERY. 


nous  in^ammations.  Large  pus  cavities  may  thus  be  formed.  The  presence  of 
fibrin  in  pm-ulent  or  seropurulent  exudates  gives  rise  to  a  fibrinopiirulent  in- 
flammation. Such  inflammatory  exudates  are  of  very  common  occurrence  in  the 
serous  cavities,  lungs,  and  upon  mucous  membranes.  The  exudate  of  an  in- 
flammatory oedema  or  phlegmonous  inflammation  often  bears  this  character. 

Suppuration. — The  steps  of  a  suppuration  may  be  traced  as  follows:  There 
is,  first,  a  primary  tissue  lesion,  either  degenerative  or  necrotic.  This  is  fol- 
lowed by  hypersemia,  marginal  disposition  of  the  leucocytes,  collection  in  the 
tissues  of  mononuclear  cells,  diapedesis  of  leucocytes  with  pol}Tnorphous  nuclei, 
phagocytosis,  and  increasing  emigration  of  the  leucocytes  until  the  tissue  be- 


FiG.  42. — Purulent  Bronchitis.  Peribronchitis,  and  Peribronchial  Bronchopneumonia  in  a  Child  one 
year  and  three  montlis  old  (Mueller's  fluid,  h::ematoxylin-eosin).  a,  Purulent ;  b,  mucoid  broncliial  con- 
tents; c,  Ci,  broncliial  epithelium  infiltrated  with  round  cells  and  partly  desquamated;  d,  infiltrated 
bronchial  wall  "n-ith  greatly  dilated  blood-vessels;  e,  infiltrated  peribronchial  and  periarterial  connective 
tissue ;  /,  alveolar  septa,  in  part  infiltrated  with  cells ;  g,  fibrinous  exudate  in  the  alveoli ;  h,  alveoli  filled 
with  exudate  rich  in  cells;  i,  alveoli  filled  with  exudate  containing  few  cells;  k,  cross-section  of  a  pul- 
monary artery;  I,  bronchial,  peribronchial,  and  interacinous  vessels  showing  marked  congestion.  X  43. 
(After  Ziegler.) 


comes  denselj'  packed.  The  injured  or  necrotic  tissue  elements  now  undergo  a 
liquefaction,  while  the  leucocytes  contained  in  the  fluid  thus  formed  begin  to 
degenerate.  Both  primary  and  secondary  tissue  damage,  therefore,  usually 
occurs  in  an  area  of  suppuration.  The  tissue  may  be  killed  at  once  by  the  in- 
jurious agent  or  it  may  be  damaged,  to  die  later  during  the  process.  The  leu- 
cocyte collection,  the  fluid  exudate,  the  abnormal  conditions  of  pressure  and 
nutrition,  the  disturbance  of  relationship,  possibly  also  chemical  substances  pro- 
duced by  the  body  cells,  etc.,  play  a  part  in  the  secondary  liquefaction  which 


INFLAMMATION. 


123 


always  distinguishes  a  suppurative  process.  It  is  very  probable  that  the  leuco- 
cytes play  a  chief  part  in  this  dissolution  of  the  dead  or  damaged  tissue.  In  all 
acute  suppurative  processes  and  in  all  exudates  rich  in  leucocytes,  peptones  and 
albumoses  are  found,  and  their  formation  may  be  the  result  of  an  extracellular 
action  of  the  leucocytes.  Such  a  "digestion"  of  the  dead  area  may  also  be 
interpreted  as  protective  or  reparative.  Upon  a  surface  the  dead  tissue  is  usu- 
ally cast  off  before  complete  liquefaction  has  taken  place.  In  demarcating 
inflammations  the  process  of  liquefaction  takes  place  only  at  the  periphery  of 
the  dead  area  where  the  leucocytes  have  assembled.  The  involvement  of  the 
leucocytes  in  the  liquefaction  process  may  be  explained  by  the  abnormal  condi- 
tions under  which  the  cells  are  placed,  the  failure  of  reproduction,  bacterial  sub- 
stances producing  leucolysis,  etc.  When  the  area  of  necrosis  is  very  large  the 
process  of  suppuration  is  usually  incomplete  and  takes  place  only  at  the  periph- 


Tic    4S— II       at  ^ono      St 
■cut  m  ibcl    I  indk      b   pur  lent 


l\lo     OPUS  M\o<5ts  (al     1  ol   1  J       to\         eob    ) 
scrap   r  1  ent   partl_     oagulated  exudate       X  45 


a  Trans    5rsely 
(  ifter  Z  egler.) 


ery  of  the  necrotic  tissues.  In  the  case  of  deep-seated  areas  of  this  kind,  there 
is  left  behind  a  fatty  debris  which  ultimately  undergoes  caseation  or  liquefac- 
tion, or  may  become  inspissated  and  impregnated  with  lime  salts.  Histolysis — 
that  is,  tissue  liquefaction — is  the  essential  feature  of  suppuration,  and  this  is 
brought  about  by  proteolytic  ferments  produced  by  the  body  cells  and  the 
bacteria. 

Pus. — The  purulent  exudate  upon  a  free  surface  and  the  product  of  suppura- 
tion are  both  called  pus.  It  appears,  ordinarily,  as  a  creamy  fluid,  more  or  less 
mucoid,  having  usually  an  alkaline  reaction,  although  not  infrequently  acid,  and 
having  a  peculiar  sweetish  odor.  When  poured  into  a  glass  cylinder,  pus  com- 
monly separates  into  two  layers — the  upper  one  consisting  of  a  transparent,  yel- 


124  AMERICAN  PRACTICE  OF  SURGERY. 

lowish  fluid  {"liquor  puris"),  while  the  lower  layer  is  thick,  opaque,  whitish  or 
yellowish  in  color,  and  consists  of  the  more  solid  constituents.  The  upper  layer 
resembles  the  lymph  and  blood  serum  in  its  composition.  The  albumin  content 
is  generally  somewhat  lower,  but  it  may  be  higher.  Fibrinogen,  as  a  rule,  is  not 
present,  so  that  pus  ordinarily  does  not  coagulate.  Globulin,  albumose,  leucin, 
tyrosin,  and  other  extractives,  more  or  less  mucin  or  pseudomucin,  fats,  choles- 
terin,  etc.,  are  found  in  pus.  The  chief  salts  present  are  sodium  chloride  and 
magnesium  and  calcium  phosphate.  Proteolytic  ferments,  antibacterial  and 
antitoxic  substances,  arising  from  the  bacteria  and  from  the  body  cells,  are  also 
contained  in  the  serum  of  pus.     The  specific  gravity  varies  from  1.030  to  1.033. 

As  might  be  expected  from  the  varied  etiology  and  the  varying  conditions 
under  which  pus  is  formed,  both  its  macroscopical  appearances  and  its  chemical 
composition  vary  greatly.  It  may  be  thin  {"ichor"),  having  a  low  specific 
gravity  and  containing  flakes  and  shreds  of  fibrin.  Lactic,  butyric,  valerianic, 
and  other  organic  acids  may  be  contained  in  it  and  give  it  their  characteristic 
odor.  Hydrogen  sulphide  (HoS)  may  be  present  in  it,  and  pus  containing  so 
many  gas  bubles  as  to  give  it  a  foamy  appearance  may  be  seen  in  case  of  infec- 
tions with  the  gas-forming  organisms.  A  very  foul  odor  may  be  occasioned  by 
the  growth  of  putrefactive  organisms.  The  presence  of  blood  may  give  it  a 
bright  red  or  brown  or  chocolate  color  {sanies).  A  blue  or  green  color  may 
be  given  to  pus  by  the  Bacillus  pyocyaneus.  An  orange-colored  pus  may  be 
produced  by  a  deposit  of  crystals  of  hsematoidin.  Red  pus  occurs  rarely  as  the 
result  of  the  presence  of  a  large  chromogenic  bacillus.  It  may  be  distinguished 
from  bloody  pus  by  the  fact  that  the  red  color  does  not  change  upon  the  dressings 
when  dry,  while  blood  soon  takes  on  a  brown  color.  A  fecal  color  and  odor  may 
be  present  in  pus  in  the  peritoneal  cavity,  or  such  pus  may  be  bile-stained. 

The  chief  cellular  constituent  of  pus  is  the  polynuclear  leucocyte.  A  pus  cell 
is  nothing  more  than  a  leucocyte.  In  fresh  pus  the  nuclei  of  the  pus  cells  may 
stain  as  well  as  those  of  the  cells  of  the  inflammatory  inflltration.  Usually 
after  suppuration  is  established  numerous  degenerating  cells  are  found  in  the 
pus,  their  protoplasm  showing  fatty  and  granular  degeneration.  In  old  pus 
nearly  all  of  the  pus  cells  may  show  karyorrhexis  or  karyolysis.  Besides  the 
polymorphonuclear  leucocytes  there  may  also  be  foimd  in  pus  eosinophile  cells, 
large  hyaline  mononuclear  cells,  as  well  as  cells  of  the  small  lymphocyte  type. 
Occasionally  the  mononuclear  cells  may  predominate.  The  older  the  process 
the  greater  the  proportion  of  mononuclear  cells,  as  a  rule.  The  nuclei  of  the 
pus  cells  are  usually  very  irregular  in  shape,  probably  as  the  result  of  amoeboid 
motion  at  the  time  of  fixation,  or  the  varied  nuclear  shapes  may  be  due  to  be- 
ginning karyorrhexis.  Round,  oval,  or  spindle  cells,  arising  from  the  prolifera- 
tion of  the  fixed  connective-tissue  cells  or  endothelium,  may  also  be  present  m 
the  pus.  There  is  as  yet  no  method  of  distinguishing  between  the  round  cells 
of  the  Ijmiphocyte  type  and  those  arising  from  the  tissue  cells.     Cellular  detritus 


INFLAMMATION.  125 

resulting  from  the  primary  tissue  lesion  and  the  suppurative  process  are  also 
contained  in  pas.  Shreds  of  tissue,  blood,  blood  pigment,  fibrin,  parasites, 
foreign  bodies,  caseous  and  calcareous  masses,  cyst  contents,  hyaline  bodies,  etc., 
may  at  times  be  found  in  pus.  The  cells  of  the  pus  produced  by  pyogenic  or- 
ganisms are  of  the  same  character  as  those  occurring  in  pus  produced  by  means 
of  chemical  irritants.  In  so  far  as  the  body  reaction  is  concerned,  there  is  ab- 
solutely no  difference  in  the  morphology  of  the  two  kinds  of  pus  formation. 

Since  purulent  reactions  are  in  the  great  majority  of  cases  due  to  pyogenic 
infections,  there  may  be  found  in  the  pus,  as  a  rule,  the  organisms  producing  it. 
Their  presence  may  be  demonstrated  by  cultural  methods  or  by  stained  prepa- 
rations of  the  pus.  In  the  case  of  some  organisms — actinomyces,  for  example 
— grayish  or  yellowish  granules  are  formed  by  the  organism,  and  these  may  be  seen 
macroscopically.  In  many  cases,  however,  the  pus  is  sterile,  the  infecting  or- 
ganisms having  been  wholly  destroyed.  The  death  of  the  bacteria  causing  the 
purulent  reaction  is  ascribed  to  the  action  of  bactericidal  substances  produced 
by  the  bacteria  themselves  or  by  the  body  cells.  The  latter  source  is  the  more 
important.  Sterile  pus  possesses  bactericidal  properties  to  a  greater  extent  than 
does  normal  blood  serum  or  lymph.  We  must  believe  that  pus,  in  its  essential 
elements,  leucocytes  and  serum,  is  protective.  Phagocytosis  and  the  formation 
of  antibodies  constitute  its  chief  functions.  In  this  sense,  then,  all  pus  is  laudable. 
Inasmuch  as  the  purulent  reaction  varies  in  degree  according  to  the  virulence  of 
the  infective  agent,  pus  has  come  to  be  itself  regarded  as  the  harmful  agent. 
The  etiological  agent  should  not  be  confounded  with  the  reaction  to  the  injury 
produced  by  it.  Pus  may  be  dangerous,  in  that  it  may  contain  the  pyogenic 
organisms  or  because  of  certain  conditions  favoring  secondary  tissue  damage; 
but  the  essential  biological  fact  should  not  be  lost  sight  of — the  'production  of  pus 
is  a  protective  reaction  to  injury.  The  limitation  of  the  term  pus  to  that  pus 
alone  which  contains  pyogenic  bacteria  is  a  purely  arbitrary  usage  and  not 
practical.  Hueter's  dictum,  that  pus  can  be  produced  only  by  pyogenic  organ- 
isms, has  been  many  times  disproved.  Further,  in  a  great  many  cases  of  infec- 
tion with  pathogenic  bacteria,  the  latter,  by  the  time  suppuration  has  occurred 
and  pus  has  formed,  have  been  entirely  destroyed,  and  the  resulting  pus  is  sterile. 
Further,  the  so-called  pyogenic  organisms  may  give  rise  to  simple,  serous,  or 
fibrinous  reactions,  instead  of  purulent.  Inasmuch,  however,  as  clinically  puru- 
lent inflammations  are  almost  without  exception  due  to  micro-organisms,  it  is 
easily  understood  why  many  clinicians  come  to  regard  the  process  and  the  in- 
fective agent  as  having  the  same  significance. 

The  purulent  reaction  is  due,  in  the  great  majority  of  cases,  to  infection  with 
the  Staphylococcus  aureus,  albus,  and  citreus  and  the  Streptococcus  pyogenes. 
Next  to  these,  rank  as  the  most  common  pyogenic  organisms  the  Diplococcus 
pneumonia',  Bacillus  mucosus  capsulatus.  Bacillus  coli  communis.  Bacillus  p])o- 
cyaneus,  Bacillus  typhi  abdominalis,  Bacillus  influenzce,  and  Actinomyces.     Other 


126  AilERIC.^N  PRACTICE  OF  SURGERY. 

organisms  more  rarely  exciting  purulent  reactions  are  Micrococcus  tetragenus, 
bacilhis  of  chicken  cholera,  'bacillus  of  swine  plague,  Micrococcus  intracellularis, 
Bacillus  prodigiosus,  Proteus  Zenkeri,  Micrococcus  pyogenes  fcetidus,  Bacillus 
mallei,  a  variety  of  Blastomycetes  not  yet  classified,  Oidium  albicans,  Tricophyton 
toiisurans,  Sporothrix  ScJienckii,  Bacilhis  aerogenes  capmlatus,  Bacillus  anthracis. 
Bacillus  tuberculosis,  etc.  Of  the  animal  parasites,  the  ameeba  of  dysentery  is 
associated  in  such  a  way  with  abscess  of  the  liver  as  to  make  it  very  probable 
that  it  is  the  etiological  factor. 

Among  the  chemical  substances  that  produce  a  pmulent  reaction  when  intro- 
duced into  the  tissues  are  mercury,  oil  of  turpentiue,  creolin,  croton  oil,  silver 
nitrate,  petroleum,  zinc  chloride,  digitoxin,  bacterial  proteins,  also  animal  and 
vegetable  proteins.  Practically,  such  chemical  suppurations  are  almost  wholly 
experimental  and  are  rarely  met  with  clinically  except  as  the  result  of  hypo- 
dermic injections.  The  suppurations  produced  by  chemical  agents  are  histo- 
logically and  biologically  exactly  the  same  as  those  produced  by  pyogenic 
organisms.  They  differ  from  the  latter  only  in  that  thej'  do  not  contain  infec- 
tive agents  capable  of  indefinite  grovsih,  that  they  heal  more  easily,  do  not 
spread,  and  do  not  give  rise  to  metastasis. 

The  common  pyogenic  organisms  are  constantly  present  upon  the  skin,  in 
the  respiratory  and  genital  tracts.  A  lowering  of  the  local  resistance,  as  through 
a  wound,  is  usually  necessarj'  for  infection.  The  occurrence  of  suppuration  is, 
however,  favored  by  acute  and  chronic  infectious  diseases,  chronic  valvular  dis- 
eases, diabetes  mellitus,  etc.  Variola,  scarlatina,  diphtheria,  typhoid  fever, 
gonorrhoea,  measles,  dysentery,  and  influenza  predispose  greatly  to  secondary 
infections  with  the  Streptococcus  pyogenes  and  other  pyogenetie  bacteria.  Mixed 
pj'Ogenetic  infections  are  not  uncommon,  the  staphylococcus  and  the  strepto- 
coccus being  most  frequentlj'  associated. 

The  general  sjonptoms  of  purulent  inflammation  are  more  marked  than 
those  of  simple  reactions.  The  affected  area  is  greatly  swollen,  tense,  and 
bra-nmy,  and  of  a  bright  red  color.  The  local  pain  is  severe  and  of  a  throbbing 
or  boring  character.  In  the  case  of  suppurative  processes  there  is  usually  a  chill 
or  there  are  repeated  chilly  sensations,  with  a  sudden  rise  of  temperature.  The 
fever  usually  persists  until  the  pus  is  discharged.  In  the  case  of  an  abscess  on 
the  surface  of  the  body,  the  advent  of  suppuration  is  shown  by  the  softening  of 
the  centre  of  the  inflamed  area  and  by  fluctuation.  At  the  centre  of  the  soft 
area  a  light-colored  spot  appears,  which  ultmiately  ruptures  by  "pointing." 
After  the  free  discharge  of  pus  the  general  and  local  sjTiiptoms  gradually  dimin- 
ish. The  hyperemia  disappears,  and  the  swelling  lessens  so  that  the  skin  be- 
comes wrinkled,  and  the  pain  ceases.  Should  the  fever  and  other  constitu- 
tional symptoms  persist,  an  extension  of  the  process  locally  may  be  taking  place 
or  metastasis  of  the  infective  agent  has  occurred. 

Purulent  inflammations  show  a  tendency  to  spread  in  the  direction  of  least 


INFLAMMATION.  127 

resistance.  They  may  be  subfascial  or  subperiosteal  and  spread  along  beneath 
the  fascia  or  the  periosteum.  In  the  muscles  the  inflammation  extends  along 
the  intermuscular  connective  tissue.  It  also  follows  along  the  blood-vessels  and 
nerve  trunks.  The  symptoms  of  deep  suppuration  develop  more  gradually  than 
when  the  process  is  superficial.  Pain  and  fever  are  the  first  signs;  there  may 
be  no  swelling  or  surface  redness.  The  surface  of  the  inflamed  region  may  then 
become  oedematous,  and  later  red  and  tender.  As  the  process  approaches  the 
surface  the  symptoms  become  more  marked  and  characteristic. 

The  condition  of  pyaemia  or  septictemia  may  develop  in  the  case  of  any  local 
purulent  inflammation.  The  constitutional  symptoms  become  correspondingly 
more  severe,  the  fever  more  marked,  chills  more  frequent,  and  a  typhoid  state 
may  supervene.  The  clinical  picture  may  be  further  marked  by  the  effects  of 
the  toxins  upon  the  heart  muscle,  kidneys,  etc.  The  case  may  finally  terminate 
in  cardiac  insuflSciency  or  uraemia.  The  purulent  process  may  spread  diffusely 
throughout  the  tissues  (phlegmon).  When  it  occurs  on  a  body  surface,  there  is 
seen  an  advancing  line  of  redness  and  swelling.  The  constitutional  symptoms  are 
usually  marked.  The  involvement  of  the  regional  lymphatics  is,  as  a  rule,  a  dan- 
gerous matter  and  demands  prompt  and  energetic  treatment.  The  primary  infec- 
tion is  often  insignificant  or  the  entrance  of  the  infective  agent  is  not  noticed. 
The  superficial  l3miphatics  running  from  the  point  of  entrance  become  swollen 
and  palpable,  and  appear  as  red  lines  or  cords.  The  lymph  nodes  are  swollen 
and  tender. 

Treatment  of  Pueulent  Infl,\mmations. — The  chief  indication  is  the  re- 
moval or  destruction  of  the  pyogenic  agent,  and  the  prevention  of  its  spread  by 
extension  or  metastasis.  Prompt  intervention  by  the  surgeon  is  demanded.  The 
developing  colony  of  bacteria  must  be  reached  where  possible,  and  vigorous 
antiseptic  measures  carried  out  against  it.  Free  incisions,  scraping,  curetting, 
excision,  antiseptic  douches,  etc.,  are  among  the  methods  that  may  be  carried 
out  to  this  end.  Antiseptic  poultices  and  baths  are  also  of  value.  In  the  case 
of  extensive  involvement  it  is  often  better  to  make  multiple  incisions  in  such  a 
way  as  to  secure  satisfactory  drainage.  The  incisions  should  be  made  where 
the  resulting  scar  will  not  cause  disfiguration  or  interfere  with  the  function  of 
the  part. 

The  strength  of  the  patient  must  be  kept  up  by  nutritious  and  easily  digest- 
ible food.  Alcohol  may  be  given.  Strychnine  and  digitalis  should  be  given 
according  to  the  state  of  the  heart's  action.  The  patient  should  be  kept  in  bed. 
The  local  symptoms  may  be  met  according  to  the  methods  mentioned  above  for 
the  treatment  of  simple  inflammations. 

Purulent  Catarrhs. — The  majority  of  these  conditions  are  treated  by  the 
physician  rather  than  by  the  surgeon.  The  chief  form  of  purulent  catarrh  usu- 
ally coming  within  the  field  of  surgical  practice  is  that  of  gonorrhcEal  infection. 
Purulent  catarrhs  of  the  bladder  and  upper  urinary  tract  are  also  often  treated 


128  AMERICAN  PRACTICE  OF  SURGERY. 

by  the  surgeon.  In  general,  the  local  treatment  of  these  conditions  consists  of 
antiseptic  or  aseptic  irrigation,  injections,  etc.,  while  the  general  indications  are 
met  according  to  general  principles. 

Abscesses. — The  term  abscess  is  applied  to  the  results  of  suppuration  within 
the  body  tissues;  that  is,  to  a  cavity  filled  with  the  products  of  the  liquefaction 
of  an  inflamed  area  (pus)  (see  Fig.  44).  It  is  one  of  the  most  common  forms  of 
purulent  inflammation.  There  are  numerous  clinical  varieties,  and  many  desig- 
nations are  applied  to  them  according  to  their  location,  character,  duration,  etc. 
The  term  abscess  is  also  applied  by  many  writers  to  the  collection  of  pus  in  the 
body  cavities.  Others  prefer  to  class  these  as  'purulent  effusions  or  empyemata, 
or  simply  to  use  the  terms  indicating  the  region  involved  (purulent  pericarditis, 


J 
:'-9 


---ll 


tr^_.,  . ,  .    ,_ 


Fig.  44. — Embolic  Abscess  of  thelntestinalWallwithEmbolicPurulent  Arteritis,  and  Embolic  Aneu- 
rism in  Cross-section  (alcohol,  fuchsin).  a,  6,  c,  rf,  e,  Layers  of  intestinal  wall ;  /,  remains  of  arterial  wall, 
cross-section;  g,  embolus,  surrounded  by  pus  corpuscles  lying  within  the  dilated  and  partly  suppurating 
artery;  h,  parietal  thrombus;  i,  periarterial  purulent  infiltration  of  the  submucosa;  h,  vein  showing 
marked  congestion.      X  28.      (After  Ziegler.) 

peritonitis,  etc.).  Pelvic  abscess  is  used  to  indicate  a  collection  of  pus  in  the 
pelvis  shut  off  by  adhesions.  Subdiaphragmatic  abscess  is  applied  usually  to  a 
localized  purulent  peritonitis  with  a  collection  of  purulent  fluid  between  the 
diaphragm  and  neighboring  organs,  usually  the  liver.  Special  names,  such  as 
hoil,  furuncle,  carbuncle,  whitloio,  felon,  etc.,  are  applied  to  certain  forms  of 
abscess. 

Abscesses  may  vary  in  size  from  those  which  are  microscopic  or  "pin-point" 
to  those  containing  one  or  two  litres  of  pus.  Abscesses  containing  from  four  to 
six  litres  have  been  reported.  The  large  abscesses  are  usually  found  in  the  sub- 
cutaneous or  subserous  tissues  or  in  the  intermuscular  fascia.     The  wall  of  an 


AMERICAN  PRACTICE  OF  SURGERY 


PLATE  I 


ACUTE   PURULENT  INFLAMMATION;  ABSCESS. 

{After  Ziegler.) 

Fig.  1.— Multiple  Abscesses  of  the  Skin,  due  to  Staphylococci.  (Alcohol,  carmine,  Gram's  method.) 
Child  of  three  weeks,    a.  Epithelium  ;  5,  corium  ;  c,  hair-follicle  :  d,  «,   purulent  foci  with  cocci,    x  40. 

Fia.  2. — Miliary  Purulent  Nephritis,  Caused  by  Staphylococci,  primary  focus  in  skin  (furuncu- 
losis).  (Alcohol,  methyl-violet,  carmine.)  a,  Normal  kidney  tissue;  6,  collections  of  cocci ;  c,  purulent 
focus.    X  43. 


INFLAMMATION.  129 

acute  abscess  is  made  up  of  more  or  less  degenerated  tissue  elements  infiltrated 
with  pus  cells.  The  abscess  may  be  sharply  circumscribed  or  the  suppurative 
process  may  extend  ("burrow")  along  the  paths  of  least  resistance.  As  a  rule, 
all  abscesses  tend  toward  a  surface,  where  they  "point"  or  "come  to  a  head." 
In  the  case  of  abscesses  of  the  internal  organs,  the  rupture  may  occur  into  any 
one  of  the  hollow  organs  or  body  cavities  or  passages.  Adhesive  inflammatory 
reaction  about  the  burrowing  pus  may  prevent  such  rupture.  Abscesses  that 
do  not  rupture  spontaneously  or  are  not  incised  may,  after  the  death  of  the 
pyogenic  organism,  become  organized,  calcified,  or  converted  into  a  cyst.  Large 
ab.jcesses  become  encapsulated.  Healing  of  an  abscess  takes  place  through  the 
proliferation  of  the  cells  of  the  abscess  walls  and  the  formation  of  a  granulation 
tissue  which  gradually  fills  up  the  cavity.  The  processes  of  repair  are  aided  by 
the  evacuation  of  the  pus  and  dead  material  and  the  apposition  of  the  abscess 
walls. 

Metastatic  or  embolic  abscesses  arise  from  the  transportation  through  the  blood 
or  lymph  of  the  infective  agent.  (See  Fig.  44.)  Since  they  are  often  small,  they 
are  frequently  called  "pin-point"  or  "pin-head"  or  "miliary  abscesses."  (See 
Plate  I.,  Fig.  2.)  The  occurrence  of  secondary  foci  of  infection  and  suppuration 
constitutes  the  condition  of  pycemia.  It  occurs  most  frequently  in  the  case 
of  infections  with  the  staphylococcus,  streptococcus,  Micrococcus  lanceolatus. 
Bacillus  mucosus  capsulatus,  and  Actinomyces. 

The  treatment  of  abscesses  is  to  be  discussed  farther  on,  in  a  separate  article 
devoted  to  this  subject. 

Among  the  most  common  forms  of  abscesses  are  those  which  occur  in  the  skin 
and  subcutaneous  tissues,  known  as  pustules,  boils,  carbuncles,  felons,  etc.  (See 
Plate  I.,  Fig.  L)  Pustules  occur  most  commonly  as  the  acne  pustule,  and  are 
the  result  of  infection  of  the  hair  follicle  or  sweat  gland,  with  resulting  obstruc- 
tion of  the  duct.  The  boil  or  furuncle  differs  from  the  pustule  only  in  the 
virulence  of  the  infection  and  the  depth  to  which  the  inflammation  extends. 
The  bacteria  gain  entrance  through  the  hair  follicles  or  the  sweat  glands. 
Through  the  growth  of  the  infecting  organisms  and  their  formation  of  toxins 
there  results  an  area  of  coagulation  necrosis,  which  forms  the  "core  of  the 
boil."  The  part  usually  thus  destroyed  is  the  hair  follicle  and  its  sebaceous 
gland.  The  first  symptom  of  the  boil  is  the  formation  of  a  small  pustule  in  a 
hair  follicle,  accompanied  by  an  itching  sensation.  There  quickly  results  more 
or  less  infiltration  of  the  neighboring  skin  and  subcutaneous  tissues,  and  the 
boil  becomes  very  sore  and  tender  on  pressure.  A  crust  then  forms  at  the  site 
of  the  pustule.  This,  when  removed,  usually  shows  a  well-defined  circular 
opening  from  which  pus  exudes.  Into  the  opening  a  probe  may  be  passed 
for  some  distance.  The  suppuration  increases,  and  after  a  few  days  the  core 
is  expelled  and  the  cavity  heals  by  the  formation  of  granulation  tissue.  The 
staphylococcus  is  the  most  common  etiological  factor,  although  streptococcus 
xoh,  I.— 9 


130 


A.AIERIC.\N  PRACTICE  OF  SURGERY. 


boils  are  not  rare.  Boils  not  infrequently  appear  in  succession  (furunculosis). 
The  patient  usually  infects  himself  through  scratching,  but  in  these  cases  there 
is  generally  some  lowered  resistance  of  the  body  tissues. 

A  carbuncle  is  an  infective,  suppurative,  and  gangrenous  inflammation  of  the 
skin  and  subcutaneous  tissues,  beginning  as  a  boil  and  spreading  gradually 
downward  and  laterally  in  the  subcutaneous  tissue.  It  differs  from  a  boil  only 
by  the  extent  of  the  tissues  involved  and  by  the  multiple  points  of  suppuration. 
Staphylococci  are  the  most  common  bacteria  foimd  in  carbuncles.  They  occur 
usually  in  adults  and  old  persons.  As  a  rule,  they  are  situated  upon  the  back 
of  the  neck,  although  occasionally  found  elsewhere.  A  fully  developed  car- 
buncle has  a  broad,  flat  base.    Over  it  the  skin  is  elevated,  reddened,  and  ex- 


*^ 


./y 


Y^ 

'& 

■5." 

I- 

* 

fn~^ 

'*''t« 

I. 

h  \ 

fj;^/%»^v^_* 

Fig.  45. — Section  of  the  Skin  in  Erysipelas  Bullosum  (alcoliol,  alum-carmine),  a,  Epidermis;  6» 
corium :  c,  vesicle ;  d,  covering  of  vesicle ;  e,  epithelial  cells  containing  vacuoles ;  /,  swollen  cells  with 
swollen  nuclei;  g,  g\,  ca^dty  caused  by  the  liquefaction  of  epithelial  cells,  and  containing  fragments  of 
epithelium  and  pus  corpuscles:  7i,  h-mph-vessel,  partly  filled  with  streptococci;  i,  lymph-vessel  filled 
with  streptococci;  A-,  colony  of  streptococci  in  the  tissue,  i,  Z,  necrotic  tissue;  m,  cellular,  mj ,  fibrino- 
cellular  infiltration ;  n,  fibrinocellular  exudate  in  the  vesicle.      X  60.     {After  Ziegler.) 


tremely  tense.  Through  the  skin  there  may  develop  a  number  of  openings 
from  which  pus  oozes.  These  may  become  confluent  into  one  or  more  larger 
openings  through  which  large  subcutaneous  sloughs  may  be  seen.  Carbuncles 
are  often  several  inches  in  diameter.  They  reach  their  full  development  about 
the  end  of  the  second  week,  but  the  process  of  healing  may  be  delayed  over  a 
number  of  weeks.  The  larger  carbuncles  give  rise  often  to  very  grave  constitu- 
tional disturbances  and  not  rarely  result  fatally.  When  occurring  in  association 
with  diabetes  the  prognosis  is  especially  grave. 

Panaritium  or  felon  is  a  variety  of  subfascial  abscess  occurring  in  the 
fingers  or  hands.  According  to  its  location  it  may  be  classed  as  cutaneous,  ten- 
dinous, subperiosteal,  or  palmar.  The  infection  occurs  through  some  slight 
skin  injury,  such  as  an  abrasion,  blister,  callus,  punctured  wound,  cut,  etc. 


INFLAMMATION.  131 

Cooks,  dish-washers,  dissectors,  etc.,  are  especially  liable  to  these  forms  of  in- 
fection. The  felon  occurs  most  frequently  at  the  ends  of  the  finger.  The 
symptoms  are  intense,  throbbing  pain,  with'  a  gradually  increasing  swelling, 
more  or  less  fever,  and  symptoms  of  general  intoxication.  The  complications, 
sequelse,  and  the  prognosis  of  felons  depend  upon  the  relations  of  the  felon  to 
the  structures  of  the  part  involved.  Tendinous  felons  may  destroy  a  phalanx 
or  seriously  injure  a  joint.  More  serious  results  of  the  same  nature  are  caused 
by  the  subperiosteal  felon.  Lymphangitis  and  secondary  involvement  of  the 
regional  lymph  nodes  are  especially  likely  to  occur  in  association  with  felons. 

Phlegmonous  inflammations  are  those  characterized  by  rapid  and  diffuse  spread- 
ing through  the  tissues  (see  Figs.  45  and  46).  They  are  usually  the  result  of  a 
streptococcus  infection.  The  signs  of  an  acute  inflammation  are  present  over  a 
large  area.  Sloughing  takes  place  early  and  suppuration  is  soon  established. 
Felons  not  infrequently  give  rise  to  such  processes.  The  whole  arm  may  be 
quickly  involved,  the  skin  becoming  hard  and  brawny,  covered  with  blebs,  and 
the  tissues  of  the  limb  as  a  whole  very  oedematous.  Occasionally  the  process 
resembles  that  of  a  malignant  oedema,  the  subcutaneous  tissue  becoming  emphy- 
sematous. This  condition  is  probably  the  result  of  an  infection  with  the  Bacil- 
lus aerogenes  capsulatus.  The  occurrence  of  a  true  malignant  oedema  in  man  is 
still  imsettled.  The  constitutional  symptoms  of  phlegmonous  inflammations  are 
usually  marked.  The  condition  of  septiccemia  is  ordinarilj'  present  at  the  same 
time.     The  treatment  is  the  same  as  that  for  abscess. 

Ulcer. — The  term  ulcer  has  been  rather  loosely  applied  by  different  writers 
to  a  number  of  conditions  which  resemble  each  other  in  that  there  is  a  loss  of 
continuity  of  a  surface,  either  that  of  the  skin  or  that  of  a  mucous  membrane .  The 
results  of  suppuration,  superficial  necrosis,  granulating  wounds,  etc.,  have  all 
been  included  under  this  head.  The  pathological  picture  ultimately  presented 
by  these  conditions  is  the  same.  In  a  broad  sense,  then,  ulcers  might  be  defined 
simply  as  a  loss  of  continuity  or  a  superficial  loss  of  substance  of  the  skin  or 
mucous  membrane,  due  to  some  form  of  tissue  lesion.  Clinically,  however,  the 
term  has  come  to  convey  the  impression  that  the  loss  of  substance  is  the  result, 
either  wholly  or  in  part,  of  the  inflammatory  reaction — that  is,  the  result  of 
suppuration  or  a  demarcating  inflammation.  The  term  ulceration  is  used  by 
some  writers  as  a  synonym  for  ulcer,  by  others  to  indicate  an  extensive  process 
or  the  occurrence  of  multiple  ulcers,  while  in  the  pathological  usage  of  the  term 
it  indicates  the  process  rather  by  which  the  ulcer  is  formed. 

The  clinical  variety  of  ulcers  is  very  great.  They  are  classed  according  to 
the  etiology,  their  location,  and  their  characteristics  of  spreading,  healing,  etc. 
According  to  etiology  they  are  usually  classed  as  non-specific  ulcers,  specific,  and 
malignant.  The  non-specific  ulcers  include  all  those  cases  which  are  not 
due  to  some  specific  infection  or  to  malignant  disease.  They  are  the  result  of 
trauma,  infection  with   pyogenic  or  saprophytic  bacteria,  anaemia,  pressure. 


132 


AMERICAN  PRACTICE  OF  SURGERY. 


-r 


local  or  constitutional  disease,  etc.  Tlie  specific  ulcers  are  those  occurring  in 
syphilis,  tuberculosis,  dysentery,  typhoid  fever,  diphtheria,  glanders,  malaria, 
actinomycosis,  blastomj'cosis,  leprosj',  etc.  The  malignant  ulcers  arise  through 
the  degeneration  or  infection  of  a  superficial  malignant  tmnor.  Carcinoma 
of  the  mouth  cavity,  oesophagus,  stomach,  intestine,  and  uterus,  epithe- 
lioma, and  rodent  ulcer  are  the  most  frequent 
malignant  timaors  giATng  rise  to  ulcer.  Sarcoma 
of  superficial  parts  less  frequently  ulcerates.  A 
malignant  growth  may  also  arise  in  a  chronic 
ulcer,  the  so-called  "malignant  degeneration" 
of  an  ulcer. 

According  to  theu*  course  ulcers  are  classed 
as  acute,  subacute,  and  chronic.  According  to  their 
condition  they  are  described  as  liealing,  spread- 
ing, inflamed,  phagedenic,  sloughing,  serpiginous, 
indolent,  fungating,  scirrhous,  hemorrhagic,  etc. 

Ulcers  occur  more  often  in  adult  life  and  in 
old  age.  They  are  much  more  frequent  in  men 
than  in  women,  and  are  generally  seen  in  indi- 
viduals of  the  lower  classes.  These  facts  are 
easily  explained  by  the  importance  of  trauma, 
sj'jDhilis,  and  the  occurrence  of  infection  as  the 
etiological  factors.  j\Iany  constitutional  dis- 
eases, such  as  diabetes,  scur^'^^,  s3-philis,  tuber- 
culosis, anjemia,  etc.,  predispose  to  the  oc- 
cm'rence  of  ulcers.  The  acute  infections, 
rt^ifi!^~if-^  f'?  particularly  typhoid  fever,  variola,  and  scarla- 
tina, favor  the  development  of  ulcers  from  ex- 
citing causes  that  otherwise  usually  are  without 
effect.  Chronic  diseases,  such  as  chronic  val- 
vular lesions  of  the  heart,  fatty  heart,  arterio- 
sclerosis, obesity,  etc.,  similarly  predispose  to 
the  formation  of  ulcers.  Local  predisposing 
causes  may  be  found  in  any  thing  interfering 
with  the  arterial  circulation,  the  venous  or  the 
IjTnphatic  circulation.  Vasomotor  distm'bances  often  plaj^  an  important  part 
in  the  development  of  ulcers.  Certain  forms  of  skin  diseases  (herpes,  ecthyma, 
pemphigus,  eczema,  etc.)  are  frequentlj'  associated  with  ulceration.  Ulcers 
maj'  also  be  produced  by  the  elimination  of  certain  drugs  (ulcerative  stomatitis 
and  ulcerative  colitis  caused  by  mercurial  poisoning,  etc.). 

The  bacteriology  of  ulcers  is  extremely  varied.     Nearly  all  the  pathogenic 
micro-organisms  may  be  foimd  as  etiological  agents  in  the  production  of  ulcera- 


^  c 


Fig.  46. — Phlegmon  of  the  Sub- 
cutaneous Tissue,  with  Formation  of 
a  Vesicle  through  CEdema  (Mueller's 
fluid,  hfematoxylin,  eosin).  a,  Co- 
rium ;  6,  epidermis ;  c,  infiltrated  fat 
tissue;  d,  focus  of  pus;  e,  cellular 
foci  in  coriinn ;  /,  subepithelial  ves- 
icle due  to  oedema.  X  30.  (After 
Ziegler.) 


INFLAMMATION.  13? 

tion.  The  typhoid  bacillus,  Shiga  bacillus,  diphtheria  bacillus,  the  amoeba  coli, 
the  malarial  plasmodium,  etc.,  are  among  the  specific  agents  which  may  under 
certain  conditions  give  rise  to  ulcers.  Not  infrequently  the  only  micro-organ- 
isms found  in  ulcers  are  saprophytic  bacteria. 

Microscopically,  an  acute  ulcer  shows  a  superficial  loss  of  substance  with  an 
infiltrated  base  and  edges.  Over  the  base  there  is  a  layer  of  exudate  and  tissue 
debris.  Sooner  or  later  proliferation  of  the  connective-tissue  cells  at  the  periph- 
ery gives  rise  to  the  formation  of  granulation  tissue,  and  the  ulcer  heals  by  sec- 
ond intention.  The  prolongation  of  the  healing  process  gives  rise  to  the  forma- 
tion of  scar  tissue  about  the  ulcer  and  a  hyperplastic  condition  of  the  bordering 
epithelium. 

The  most  common  forms  of  ulcer  seen  by  the  surgeon  are  the  syphilitic, 
varicose,  traumatic,  and  pressure  ulcers  (decubitus).  The  treatment  of  ulcers  is 
both  general  and  local.  The  constitutional  treatment  consists  in  the  support 
and  building  up  of  the  body  by  means  of  proper  diet  and  hygiene,  tonics,  etc. 
The  local  treatment  is  aimed  at  the  cleansing  and  sterilization  of  the  ulcer,  the 
stimulation  of  repair,  and  the  control  of  the  reparative  process.  In  the  case  of 
a  recently  formed  ulcer  the  local  treatment  is  that  carried  out  in  any  suppura- 
tive process,  being  directed  against  the  infective  agent  and  also  aimed  at  the 
relief  of  the  inflammatory  symptoms.  For  further  details  the  reader  is  referred 
to  the  article  on  Ulcers  and  Ulceration. 

Fistula,  Fistulous  Tract,  and  Sinus. — An  abnormal  opening  into  a  normal 
body  cavity  or  organ  is  known  as  a  fistula.  The  term  is  also  applied  to  congeni- 
tal openings  or  defects  as  well  as  to  openings  produced  by  suppurative 
processes.  "When,  as  the  result  of  a  "  burroAving "  suppuration,  there  is  formed 
a  long,  narrow  channel,  the  latter  is  designated  a  fistulous  tract  or  sinus.  These 
conditions  are  usually  characterized  by  a  failure  of  the  healing  process.  They 
are  often  due  to  the  presence  of  a  foreign  body,  infected  ligature,  etc.,  or 
the  position  of  the  fistula  is  such  that  the  body  movements  keep  it  from 
healing.  Piiysiological  secretion  (urine,  saliva,  fteces,  bile,  etc.)  may  serve  to 
keep  the  fistula  from  closing.  Further,  many  fistulas  are  the  result  of  tubercu- 
lous infection. 

Wlien  the  fistulous  tract  or  sinus  is  superficial,  it  should  be  opened  by  a  free 
incision  and  its  surfaces  curetted.  Foreign  bodies,  ligatures,  etc.,  should  be 
carefully  f  lught  and  removed.  Small  tuberculous  fistulas  may  be  removed 
entire.  In  other  cases  a  careful  dissection  of  the  wall  may  be  carried  out. 
Treatment  with  antiseptic  washes,  irrigation,  injection,  etc.,  may  be  instituted 
according  to  indications.  As  the  fistula  and  sinus  show  little  disposition  to  heal 
and  so  tend  to  run  a  protracted  course,  careful  search  should  be  made  to  ascer- 
tain the  cause  and  source  of  the  condition,  and  all  diseased  tissue  should  be 
thoroughly  removed.  Constitutional  treatment  is  often  of  the  greatest  impor- 
tance, particularly  when  tuberculous  infection  is  suspected. 


134  AMERICAN  PRACTICE  OF  SURGERY. 

5.  Acute  Degenerative  and  Necrotic  iNFLAiiMATiONS. 

■\;^^len  an  organ  or  tissue  presents  extensive  parenchj-matous  degeneration, 
such  as  clotidy  sweUmg,  fatty  degeneration,  etc.,  without  evidences  of  an  inflam- 
matory reaction,  the  condition  is  usually  spoken  of,  both  clinically  and  patho- 
logically, as  that  of  "acute  degenerative  parenchymatous  infla^nmation."  In  re- 
ality it  represents  the  tissue  lesion  alone,  without  any  inflammatory  reaction 
as  yet  having  been  initiated.  Such  processes  are  seen  particularly  in  the  liver 
and  kidneys,  and  are  usually  the  result  of  intoxications,  either  from  bacterial 
infections  or  from  chemical  poisons.  The  use  of  the  term  inflammation  is,  of 
course,  not  justified  from  the  pathological  standpoint,  and  it  would  be  more 
proper  to  class  them  as  degenerations.  The  fact  that  no  inflammatory  reaction 
is  found  is,  however,  due  to  the  death  of  the  patient  before  it  has  had  time  to 
develop;  in  fact,  all  stages  may  be  found  in  different  cases,  from  the  pure  de- 
generation or  necrosis  to  a  fully  developed  condition  of  inflammation.  There 
is,  therefore,  a  certain  practical  reason  for  classing  all  these  conditions  imder  the 
head  of  degenerative  mflammation.  To  the  surgeon  these  conditions  are  of 
great  importance,  since  they  most  frequently  arise  from  the  absorption  of  bac- 
terial toxins  from  some  local  focus  of  infection.  To  an  acute  degenerative 
nephritis  or  myocarditis  the  fatal  termination  in  septicaemia,  septicopysemia, 
and  saprsemia  is  usually  due.  The  treatment  is  chiefly  preventive.  The  con- 
trol of  the  local  infection,  its  restriction  from  spreading,  the  promotion  of  excre- 
tion of  poisons  absorbed,  etc.,  are  the  chief  indications  of  treatment. 

Some  of  the  injurious  agents  acting  upon  the  body  produce  a  tissue  lesion  of 
the  nature  of  extensive  necrosis.  The  necrotic  tissue  remains  unchanged  for  a 
long  time,  and  is  only  rather  late  removed  by  means  of  sequestration,  sloughing, 
absorption,  etc.  In  such  cases  the  tissue  necrosis,  therefore,  becomes  the  most 
striking  feature  of  the  process,  and  such  inflammations  are  kno'mi  as  necrotic 
inflammations.  The  necrosis  may  be  apparent  before  the  inflammatory  reac- 
tion, as  in  the  case  of  burns,  corrosive  poisons,  freezing,  anaemia,  etc.  In  other 
cases,  particularly  in  infections,  the  inflammatory  reaction  may  first  be  seen, 
the  inflamed  and  infiltrated  tissues  later  becoming  necrotic.  Tuberculosis  may 
be  taken  as  an  example  of  a  necrotic  inflammation  of  the  latter  type ;  as  a  rule, 
the  caseation  necrosis  occurs  after  tissue  proliferation  has  existed  for  some  time. 
Necrotic  inflammations  are  caused  chiefly  by  high  or  low  temperatures,  anaemia, 
caustics,  and  infection.  In  the  cas&  of  the  action  of  high  or  low  temperatme  and 
anaemia,  the  tissue  necrosis  occurs  in  the  part  involved.  Corrosive  poisons  also 
act  locally,  but  manj''  poisons  produce  necrosis  not  only  at  the  point  of  contact, 
but  in  other  portions  of  the  body  as  well,  after  their  diffusion  through  the  blood 
or  Ijonph.  Mercury,  cantharidin,  the  salts  of  chromic  acid,  etc.,  cause  necrosis 
in  the  intestines,  urinary  passages,  and  kidneys,  as  well  as  at  the  points  with 
which  they  first  come  in  contact.     Bacteria  cause  necrosis  both  at  the  place 


INFLAMMATION. 


135 


where  they  multiply  and  in  those  portions  of  the  body  where  they  are  excreted 
after  being  absorbed. 

Necrotic  inflammations  are  most  frequently  seen  on  the  mucous  membranes, 
and  are  usually  called  diphtheritic  inflammations  or  diphtheritis  (see  Fig.  47).  As 
a  rule,  the  latter  designation  is  applied  only  to  those  processes  in  which  the  infil- 
trated subepithelial  connective  tissue  is  also  involved  in  the  necrosis,  but  necrosis 
of  the  epithelium  alone  is  often  spoken  of  as  epithelial  or  superficial  diphtheritis. 
The  necrotic  epithelium  may  be  recognized  by  the  occurrence  of  white  opaque 
patches.    In  a  true  diphtheritis  the 

entire  epithelial  surface  is  necrotic  .-.•;'^^?~^ -^\^- "^-v  •.'•-,.. 

as  well  as  the  upper  layers  of  con-      f   '  .'-".,  v'f~"5?S) 

nective  tissue,  the  dead  parts  be-      !:..___:::;:'  v^.,v    '■-   .  :   .  ;::i'.   '^J 

coming  changed   into   a   lumpy  or      j'       ..  ;■  ••'■7 

granular  mass  without  nuclei,  or  in-      1;  ,     .,       ,        .  v'^  ';, 

to  a  hyaline  mass  containing  fibrin.        ,,     r-^^-'v'y^.^''''^'.--       vAV  ".'-■■  ■ 
Usually  no  evidences   of  structure       .  '''V/'jV.«7s''''    V°:/A*'' .'•■V'*!'    '  .. - 

can  be  made  out  in  the  dead  mass. 
This  constitutes  the  so-called  diph- 
theritic membrane.  Such  processes 
occur  most  frequently  in  the  intes- 
tines (dysentery,  diphtheritic  colitis, 
etc.),  in  the  vagina  and  uterus  (diph- 
theritic vaginitis  and  endometritis), 
in  the  descending  urinary  tract  and 
bladder  (diphtheritic  ureteritis  and 
cystitis),  and  in  the  upper  respira- 
tory tract  (diphtheria  of  tonsils, 
fauces,  larynx,  etc.).  In  the  respi- 
rator}' tract  the  process  is  usually 
caused  by  the  Bacillus  diphtheria;, 
in  the  intestinal  and  genito-urinary 
tract  by  the  Streptococcus.  The  other  pyogenic  organisms  are  capable  under 
certain  circumstances  of  producing  a  similar  necrosis.  An  infection  of  a 
wound  by  virulent  bacteria  {Staphylococcus  or  Streptococcus,  etc.)  may  produce 
a  similar  necrosis  of  the  wound  granulations  (ivound  diphtheritis).  Necrotic 
inflammations  may  also  occur  within  the  internal  organs  as  the  result  of 
infection.  The  lymph  nodes,  spleen,  and  bone  marrow  are  most  frequently 
involved. 

The  diphtheritic  inflammations  of  most  interest  to  the  surgeon  are  those  oc- 
curring after  operations  upon  the  intestinal  and  genito-urinary  tracts  and  upon 
wounds.  The  streptococcus  is  the  most  common  etiological  agent.  The  process 
is  very  severe,  the  infection  virulent,  and  the  cases  run  usually  an  unfavora,ble 


Fig.  47. — Bacillary  Diphtheritis  of  tlie  Large 
Intestine  in  Dysentery  (alcohol,  gentian -violet). 
a,  Necrotic  portion  of  the  glandular  layer  of  the 
mucosa,  infiltrated  with  bacilli ;  b,  intact  inflamed 
mucosa;  c,  muscularis  mucosae;  d,  submucosa; 
e,  colonies  of  bacilli;  /,  glands  with  living  epithe- 
iium;  g,  glands  with  necrotic  epithelium  and  ba- 
cilli; h,  connective  tissue  infiltrated  with  cells; 
i,  blood-vessels.      X  80.     {After  Ziegler.) 


136  AMERICAN  PRACTICE  OF  SURGERY. 

course.  Diphtheritic  cohtis  and  cystitis  are  very  frequently  the  immediate 
cause  of  death.  The  latter  usually  occurs  after  operations  for  stone,  stricture, 
and  enlarged  prostate.  The  treatment  is  chiefly  preventive.  After  infection  of 
this  nature  has  occurred  and  the  process  has  become  established,  the  treatment 
is  in  general  the  same  as  that  for  suppurative  inflammations. 

If  an  area  of  inflammation  becomes  infected  with  bacteria  capable  of  pro- 
ducing putrefaction,  the  inflammatory  process  assumes  the  character  of  a  putrid 
gangrene  and  the  inflammation  is  designated  as  a  gangrenous  inflammation. 
The  term  gangrene  alone  is  usually  applied  to  the  condition.  While  the  pathol- 
ogist uses  this  term  to  denote  a  necrosis  accompanied  by  putrefactive  pro- 
cesses, the  surgeon  often  uses  it  to  designate  simply  the  death  of  tissues  e?i 
masse — that  is,  to  signify  an  extensive  necrosis  of  an  exposed  portion  of  the 
body.  As  a  matter  of  fact,  such  a  superficial  death  of  tissue  is  practically 
always  accompanied  by  decomposition,  so  that  no  essential  contradiction  exists 
in  the  different  applications  of  the  term.  The  presence  of  saprophytic  or 
putrefactive  bacteria  may,  therefore,  be  regarded  as  the  most  distinctive  feature 
of  gangrene. 

Gangrenous  inflammations  may  be  either  primary  or  secondary.  The  primary 
form  is  due  to  infection  with  some  specific  micro-organism,  and  is  to  be  regarded 
as  a  specific  form  of  gangrene.  Among  the  bacteria  capable  of  producing  a 
primary  gangrene  may  be  mentioned  the  Bacillus  aerogenes  capsulatus,  B. 
ocdematis  maligni,  B.  diphtheria!,  B.  anthracis,  B.  coli  communis,  and  probably  a 
number  of  other  bacteria  as  yet  not  well  known.  Secondary  gangrene  may  be 
caused  by  burns,  freezing,  deprivation  of  the  blood  supply,  mechanical  injury, 
pressure,  corrosive  poisons,  various  intoxications,  and  infections.  In  all  these 
cases  there  is  first  a  tissue  lesion  and  inflammatory  reaction,  associated  with  or 
followed  by  secondary  infection  with  putrefactive  organisms.  Two  chief  forms 
of  gangrene  are  recognized — dry  and  moist  gangrene.  The  former  occurs  in 
parts  exposed  to  the  air  and  therefore  after  necrosis  quickly  losing  their  water 
through  evaporation.  When  evaporation  does  not  occur,  the  parts  remain 
moist  and  present  a  better  soil  for  the  growth  of  saprophytic  organisms.  In  the 
dry  form  there  is  usually  but  little  bacterial  growth  and  consequently  less  de- 
composition; in  the  moist  form,  on  the  other  hand,  the  putrefactive  processes 
constitute  the  chief  feature.  Between  the  two  forms  there  is  no  hard-and-fast 
line.  A  moist  gangrene  may  become  converted  into  a  dry  form  by  evaporation 
of  the  fluid  contained  in  the  necrotic  area,  while  a  dry  gangrene,  through  the 
absorption  of  fluids  from  the  surrounding  tissues,  may  become  changed  into  the 
moist. 

According  to  its  origin,  gangrene  is  also  classed  as  traumatic,  thermal,  toxic, 
senile,  idiopathic,  diabetic,  neuropathic,  etc.  According  to  the  character  of  the 
process,  there  may  be  distinguished  such  forms  as  circumscribed,  diffuse,  phage- 
denic, etc.     When  the  putrefaction  is  very  marked,  the  gangrene  is  designated 


INFLAMMATION.  137 

septic  or  putrid  gangrene.  The  formation  of  gas  in  the  gangrenous  area  gives 
rise  to  emphysematous  gangrene.  When  the  tissues  contain  much  blood  before 
death,  they  are  usually  black  or  greenish  in  color  (black  gangrene);  when  anse- 
mic,  they  are  lighter  in  color,  although  always  discolored  to  some  extent  (white 
gangrene).  Clinically  these  forms  are  also  known  as  warm  and  cold  gangrene, 
respectively. 

Dry  gangrene  is  usually  circumscribed.  It  occurs  in  the  parts  of  the  body 
most  exposed  to  evaporation,  as  the  tips  of  the  ears,  nose,  fingers,  and  toes.  In 
the  great  majority  of  cases  it  is  due  to  arterial  or  venous  obstruction  by  throm- 
bosis or  embolism,  whenever  the  collateral  circulation  is  insufficient  to  keep  up 
the  nutrition  of  the  part  whose  vessels  are  affected.  It  also  occurs  after  freez- 
ing, burns,  corrosions,  in  ergotism,  diabetes,  senilitj^,  Raynaud's  disease,  etc. 
The  affected  part  is  discolored,  yellow,  brownish,  or  black,  or  the  tissues  may  at 
first  appear  bloodless  and  very  pale.  The  consistence  gradually  becomes  hard 
and  tough,  and  finally  the  part  comes  to  resemble  leather  or  the  skin  of  a  mummy. 
A  formation  of  vesicles  or  blebs  may  precede  the  mummification.  Should  these 
rupture  and  the  corium  become  denuded,  the  process  of  evaporation  is  aided. 
In  the  early  stages  the  odor  of  putrefaction  is  present,  but  is  never  very  marked. 
Around  the  dead  area  there  is  usually  present  a  more  or  less  sharply  marked  line 
of  demarcation. 

Moist  gangrene  occurs  very  frequently  after  severe  traumatism  of  the  ex- 
tremities, obstruction  of  the  arterial  or  venOus  flow,  in  certain  skin  diseases, 
diabetes,    senility,    acute     in-        _____„,^ 
fections,  etc.    Decubitus,  noma,  <  w^S^^^  ■■  ^*^*'   ,i,^ 
malum  perforans,  hysterical  gan-     -  •> 
grene  are  varieties  of  the  moist 
form  of  gangrene.     Of  the  m-       8 
ternal  organs  the  lungs  are  most     '■''  i       '^^ 

frequently  the   seat  of   moist 
gangrene.   It  follows  infarction,  { 

inspiration  pneumonia,  non-re-  '  ^.-^.^   ^^^^  ^ 

solution  of  croupous  and  puru- 
lent    pneumonia,    pulmonary 
abscess,  atelectasis,  bronchiec- 
tasis,    neoplasms,     etc.      Moist       Fig.   4S.— Gangrene  of    Portion    of    Foot.     N,   Necrosed 
gangrene      of       the      mesentery    P.°^*'°°'    ^'  "°""=  °*   demarcating    proliferations;    H,    living 
°       "^  ■'     tissue   outside  zone  of  demarcation.      (After  Ribberi.) 

follows    mesenteric    infarction 

due  to  embolism  or  thrombosis  of  the  mesenteric  arteries.  Strangulated  hernia, 
intestinal  obstruction,  intussusception,  obstruction  or  strangulation  of  the 
appendix,  traumatic  injury  of  the  pancreas,  pancreatic  inflammation,  torsion 
of  the  pedicle  of  new  growths,  floating  spleen,  kidney,  etc.,  usually  lead  to 
moist  gangrene.    Extreme  passive  congestion,   marked  oedema,  infiltration  of 


138  AMERICAN  PRACTICE  OF  SURGERY. 

the  perineal  tissues  with  urine,  retention  of  the  urine,  etc.,  are  also  conditions 
favoring  the  occurrence  of  moist  gangrene. 

Moist  gangrene  is  recognizable  clinically  by  its  foul  odor,  discoloration,  and 
progressive  softening  of  the  affected  area.  In  the  early  stages  the  color  is  usu- 
ally reddish  purple,  but  later  becomes  greenish,  brown,  or  black.  Blebs  filled 
with  a  dirty  brown  fluid  are  formed  in  the  skin  of  the  gangrenous  area.  Ulti- 
mately the  entire  part  becomes  soft  and  partially  liquefied,  and  the  phenomena 
of  putrefaction  are  presented,  as  in  the  case  of  a  dead  body.  Hydrogen  sulphide, 
ammonia,  indol,  skatol,  fatty  acids,  amins,  carbonic  acid,  and  other  gases  are 
formed  during  the  putrefactive  process.  When  the  gas  formation  is  marked,  a 
local  or  widespread  emphysema  may  be  produced.  Around  the  gangrenous  part 
there  is  usually  a  zone  of  inflammatory  demarcation  (see  Fig.  48).  .  Finally,  the 
dead  tissues  are  either  cast  off  or  are  absorbed,  calcified,  organized,  or  en- 
cysted. 

Besides  the  end  products  of  decomposition  mentioned  above,  there  are 
formed  in  the  gangrenous  tissue  diffusible  poisons,  which  when  absorbed  pro- 
duce systemic  symptoms.  The  intensity  of  the  latter  depends  upon  the  amount 
and  character  of  the  poisons  produced,  the  amount  and  rate  of  the  absorption, 
and  the  resistance  of  the  patient.  The  intoxication  may  be  so  intense  as  to 
cause  death.  In  other  cases  the  gangrenous  process  advances  until  death  is 
brought  about  by  the  involvement  of  vital  parts.  Healing  may  occur  after 
sequestration,  organization,  or  calcification. 

The  varieties  of  gangrene  met  with  in  surgical  work  are  numerous.  Senile, 
diabetic,  infective,  traumatic,  toxic,  multiple,  neuropathic,  hospital,  emphysem- 
atous, X-ray,  carbolic-acid,  decubitus,  etc.,  are  .  among  the  most  important 
clinical  varieties.     These  will  be  discussed  more  fully  under  the  proper  heading. 

The  treatment  of  gangrenous  inflammations  is,  in  general,  the  same  for  all 
varieties.  In  the  infective  cases  the  treatment  should  be  directed  along  anti- 
septic lines.  In  the  case  of  obstruction  to  the  blood  supply,  exercise,  massage, 
and  hot  baths  may  be  used  to  encourage  a  collateral  circulation  and  to  prevent 
the  occurrence  of  gangrene.  The  general  symptoms  should  be  treated  according 
to  indications.  As  the  subject  of  gangrene  from  the  clinical  standpoint  will  be 
treated  fully  ui  a  later  article,  it  will  not  be  necessary  for  me  to  enter  into 
further  details  in  this  place. 

III.  CHRONIC  INFLAMMATIONS. 

Etiology. — Tlie  causes  of  chronic  inflammation  are  to  be  sought  in  factors 
that  excite  a  progressive  tissue  lesion  and  in  those  that  prevent  prompt  healing. 
Persistent  infection,  chronic  intoxications,  repeated  injury  by  extrinsic  agents 
(dust,  repeated  rubbing,  foreign  bodies,  etc.),  unfavorable  nutritive  conditions, 
diminished  resistance,  extensive  tissue  defects,  presence  of  large  masses  of  ne- 


INFLAMMATION.  139 

erotic  tissue,  collections  of  exudate  that  are  with  difRculty  removed,  etc.,  are 
the  chief  causes  of  the  persistence  of  an  inflammatory  reaction. 

Chronic  infections  very  frequently  give  rise  to  progressive  inflammations, 
which  spread  through  the  body  by  direct  extension  and  give  rise  to  metastases 
through  the  blood  or  lymph.  Such  chronic  inflammations  are  caused  by  bac- 
teria and  certain  moulds  and  yeasts,  which  contmue  to  multiply  in  the  body 
and  constantly  to  give  rise  to  new  tissue-irritation  and  injury.  To  this  class  be- 
long chiefly  the  so-called  specific  infections,  tuberculosis,  syphilis,  leprosy, 
actinomycosis,  blastomycosis,  etc. ;  but  persistent  infections  due  to  the  ordinary 
pyogenic  bacteria,  colon  bacillus,  typhoid  bacillus,  gonococcus,  pneumococcus, 
etc.,  are  not  infrequent.  Such  inflammations  present  a  more  or  less  distinct 
clinical  course  and  s5miptomatoIogy. 

Chronic  intoxications  play  a  very  important  role  in  the  production  of  chronic 
inflammations  of  the  internal  organs,  particularly  of  the  liver  and  kidneys. 
The  chief  source  of  the  poisons  is  to  be  sought  in  the  gastro-intestinal  tract,  but 
substances  harmful  to  the  organism  may  be  taken  in  through  the  respiratory 
tract,  skin,  etc.  In  many  of  these  chronic  inflammations  of  the  internal  organs 
the  exciting  factor  is  probably  an  auto-intoxication,  the  poisonous  substances 
being  produced  within  the  body  itself  as  the  result  of  disturbed  metabolism, 
perverted  gland  function,  or  failure  of  specific  internal  secretions  (auto-intoxi- 
cations). 

Repeated  mechanical  injury,  though  of  slight  degree,  may  give  rise  to  a  per- 
sistent inflammatory  reaction.  The  repeated  inhalation  of  irritating  dusts  ex- 
cites a  chronic  pneimionia;  repeated  friction  causes  inflammations  of  the  skin 
or  mucous  membranes;  pathological  changes  in  the  contents  of  the  gastro- 
intestinal tract  may  give  rise  to  chronic  inflammations  of  the  mucosa  of  this 
tract.  The  presence  of  concretions,  foreign  bodies,  etc.,  likewise  causes  chronic 
irritation  and  a  persistent  reaction. 

Portions  of  necrotic  tissues  too  large  to  be  easily  replaced  or  removed,  or  that 
are  absorbable  with  difficulty,  act  as  foreign  bodies  and  excite  chronic  irritation 
and  reaction.  Likewise  masses  of  purulent  or  fibrinous  exudates  act  in  the  same 
manner,  and  the  reaction  persists  until  the  exudate  is  completely  organized, 
encapsulated,  or  calcified.  Large  pieces  of  necrotic  bone  may  persist  as  seques- 
tra for  a  number  of  years  and  keep  up  a  constant  inflammation.  Further,  large 
tissue  defects,  such  as  extensive  burns  and  ulcers,  require  often  many  months 
before  the  wound  surface  is  covered  over  with  epithelium  and  the  healing  process 
completed. 

Unfavorable  nutritive  conditions,  such  as  general  or  local  anaemia,  chronic 
passive  congestion,  delay  the  coiu-se  of  healing  and  also  predispose  to  inflam- 
matory conditions,  m  that  they  permit  slight  extrinsic  agents,  which  ordinarily 
produce  no  tissue  lesions  or  at  least  only  slight  ones,  to  set  up  ulcerative  inflam- 
mations that  show  little  tendency  to  heal. 


140 


AMERICAN  PRACTICE  OF  SURGERY. 


-t 


.Rr' 


c-w 


In  general,  chronic  inflammations  are  characterized  by  hyperplasia  of  the 
,   „,  .^  connective    tissues    of     the    affected 

part.  Chronic  inflammations  of  the 
-crous  membranes,  caused  by  chronic 
infection  or  by  the  presence  of  exu- 
dates not  easily  removed  or  ab- 
sorbed, are  characterized  by  exten- 
sive thickenings  of  the  membrane, 
due  to  the  organization  of  the  exu- 
"' :  ;'j  date  or  to  a  hyperplasia  of  the  con- 
'  . 'i  nective  tissue  of  the  subserosa.  (See 
j-:t,.^«-^-''^^"  Fig-  49.)  The  new  formation  of  con- 
-~"  "c"-.— -'j  nective  tissue,  therefore,  takes  place 
A^": ,  -  .-■;  either  upon  the  serous  membrane  or 
within  it.  Dense  hyaline  adhesions 
and  thickenings  mav  thus  result, 
and  the  capsule  of  such  organs  as 
the  spleen  and  liver  may  be  enor- 
mously thickened  ("Zuckerguss- 
leber,"  etc.).  Chronic  infective  in- 
flammations of  the  lung,  prolonged 
irritation  due  to  the  inhalation  of 
dusts,  etc.,  cause  a  diffuse  fibroid 
induration  of  the  pulmonary  tissue 
(chronic  fibroid  pneumonia,  stone- 
cutter's lung,  etc.).  A  persistent 
flow  of  irritating  secretions,  as  in  the 
case  of  a  chronic  gonorrhoea,  pro- 
duces a  marked  hyperplasia  of  the 
mucous  membrane  and  skin  in  the 
neighborhood  of  the  genital  orifices, 
affecting  chiefly  the  papilla  and  over- 
lying epithelium,  so  that  verrucose 
growths  are  produced  {condylomata 
acuminata).  Diffuse  hyperplasias  of 
the  connective  tissue  of  the  skin, 
known  as  elephantiasis,  may  be 
caused  by  a  persistent  or  frequently 
repeated  trauma,  the  presence  of 
parasites,  etc.  Chronic  inflamma- 
tions of  the  periosteum  and  bone 
marrow  give  rise  to  new  formations  of  bone.     In  the   case  of  the   internal 


'St-^t 


.1" 


■^M 


J 


3 


Fig.  49. — Changes  in  the  Pleura  and  Lung  after  a 
Purulent  Pleuritis  Lasting  Six  Months  (alcohol, 
orcein),  a,  Thickened  lung  tissue  with  gland-like 
alveoli,  and  elastic  fibres  in  the  newly  formed  con- 
nective tissue ;  6,  thickened  pleura ;  c,  newly  formed 
connective  tissue  without  elastic  fibres;  d.  gran- 
ulation tissue  covered  with  pus;  e,  elastic  limiting 
membrane  of  the  pleura;  /,  elastic  fibres.  X  46. 
{After  Ziegler.) 


I^FLA:\iMATIOX.  141 

organs,  chronic  inflammatory  processes  are  characterized  by  a  local  or  clifl^use 
hyperplasia  of  the  connective-tissue  stroma  (hepatic  cirrhosis,  etc.). 

Chronic  inflammations  may  be  classed  according  to  their  causes  or  to  the 
character  of  the  changes  produced  in  the  affected  part.  The  chief  forms 
are  chronic  catarrhs,  chronic  abscesses,  chronic  ulcers,  the  infective  gramdomata, 
hyperplastic  chronic  inflammations,  and  atrophic  chronic  inflammations. 

Chronic  catarrhs  of  the  mucous  membranes  may  be  caused  b}'  prolonged 
circulatory  disturbances  (chronic  passive  congestion),  chemical  irritation  result- 
ing from  pathological  changes  in  the  gastric  or  intestinal  contents,  chronic 
uifections  (gonorrhoea,  tuberculosis,  etc.),  the  presence  of  animal  parasites,  con- 
cretions, etc.  Chronic  catarrhs  of  the  genito-urinary  tract  are  the  forms  most 
frequently  falling  into  the  province  of  surgery. 

Chronic  abscesses  may  result  from  acute  abscesses  and  are  due  to  the  same 
causes.  In  other  cases  they  are  the  result  of  a  specific  infection  (tuberculosis, 
actinomycosis,  etc.),  and  develop  more  gradually  witliout  passing  through 
any  well-defined  acute  stage.  Chronic  abscesses  have  a  connective-tissue 
wall  lined  with  granulation  tissue.  They  may  contain  pus  or  a  material 
resembling  pus,  formed  by  the  partial  liciuef action  of  caseous  material  {"cold 
abscess").  The  specific  forms  of  chronic  abscesses  are  as  a  rule  easily  distin- 
guished from  other  forms  by  the  peculiar  character  of  the  granulation  tissue 
of  the  abscess  wall  and  also  by  the  presence  of  the  infective  agent.  Chronic 
abscesses  increase  in  size  as  the  result  of  a  progressive  destruction  of  the 
abscess  wall  and  the  neighboring  tissue  as  well  as  by  the  continued  forma- 
tion of  pus.  As  they  increase  in  size  extension  is  usually  governed  by  gravity 
and  the  path  of  least  resistance.  "\^Tien  enlarging  progressively  toward  the  deeper 
tissues,  they  are  spoken  of  as  "congestive"  or  "burrouring"  abscesses.  The  in- 
crease in  size  usually  indicates  the  persistence  of  the  infective  agent.  "Cold 
abscesses"  are  seen  most  frequently  in  cases  of  tuberculous  arthritis  and  osteo- 
myelitis. Tlie  contents  of  the  cavity  are,  as  a  rule,  slowly  formed.  "Cold 
abscesses"  of  the  vertebrse  extend  downward  along  the  spine  and  psoas  muscles, 
presenting  themselves  as  fluctuating  tumors  either  above  or  below  Poupart's 
ligament.  In  the  great  majority  of  cases  the  chronic  abscess  is  tuberculous. 
Chronic  abscesses  also  occur  as  sequelse  of  typhoid  fever,  influenza,  variola, 
and  others  of  the  acute  infectious  diseases. 

Chronic  idcers  (see  Fig.  50)  may  be  caused  by  non-specific  injurious  agents, 
the  ulcer  for  a  number  of  reasons  not  healing  and  consequentl}'  rimning  a 
■chronic  course.  Such  ulcers  are  usuall}'  found  on  the  inner  side  of  the  lower 
third  of  the  leg,  and  are  generally  associated  with  a  chronic  congestion  or  a 
varicose  condition  of  the  veins  of  the  part.  In  the  stomach  the  healing 
of  an  ulcer  may  be  prevented  or  delayed  by  peculiar  qualities  of  the  stomach 
contents.  In  the  majority  of  cases  chronic  ulcers  are  the  result  of  some 
specific  infection   {tuberculosis,  syphilis,   glanders,  etc.).     Chronic   ulcers  vary 


142 


MIERICAN  PRACTICE  OF  SURGERY. 


greatly  in  size,  shape,  appearance  of  base,  edges,  surrounding  tissues,  and 
general  characteristics  of  the  process.  A  very  great  variety  of  terms  is,  in 
consequence,  applied  to  them.  Wlien  extending  around  a  limb  they  are 
called  annular  ulcers.  If  healing  begins  at  one  edge  of  the  ulcer  while  the 
ulceration  advances  at  other  parts,  the  resulting  variety  is  known  as  serpig- 
inous. A  small,  slowly  progressive  ulcer  is  called  an  indolent  ulcer.  When, 
pale,  soft,  and  flabby,  the  ulcer  is  designated  weak  or  (edematous.  A  round  or 
irregular  funnel-shaped  ulcer  is  styled  perforating  ulcer.  Wlien  covered  with  a 
grayish  or  yellowish-white  necrotic  layer  composed  of  fibrin  and  necrotic  cells, 
the  ulcer  may  be  classed  as  a  croupous  or  diphtheritic  ulcer.  Raiv  ulcers  are 
those  in  which  the  base  of  the  ulcer  is  composed  of  the  body  tissues,  muscle  or 
connective  tissue.     A  dense,  callous  thickening  of  the  edge  and  base  of  the  ulcer 


I    «"" 


%''1J.-\ 


^^:^i 


*%!  \  ^'^  ;  X-^ 


>i 


-../,  ^j«_.c--^r^\;5V, 


Fig.  50. — Floor  of  Chronic  Ulcer,   a,  Superficial  layer  of  purulent  exudate;  6,  zone  of  chronic  granu- 
lation tissue;   c,  tissue  at  base  of  ulcer.     (After  Weichselbaum.) 


gives  origin  to  the  form  known  as  cnlloiis  ulcer.  Excessive  formation  of  granu- 
lation tissue  produces  an  idcus  elevatum  hypertrophicum.  The  base  of  an  ulcer 
may  be  either  lower  or  higher  than  the  surrounding  tissue;  it  may  be  pigmented. 
The  edges  may  be  sharply  outlined  or  irregular,  thin  or  thick,  adherent,  over- 
hanging, romided,  elevated,  undermined,  "  worm-eaten,"  etc.  They  are  usually  of 
a  uniform  height.  The  tissue  about  a  chronic  ulcer  may  be  red,  swollen,  cedem- 
atous,  pigmented,  eczematous,  etc.  Smaller  ulcers  may  be  grouped  about  the 
main  one.  There  is  usually  only  a  small  amount  of  discharge  from  a  chronic 
ulcer.  The  symptoms  are  much  less  intense  than  in  the  case  of  an  acute  ulcera- 
tion, except  when  nerves  are  directly  involved. 


INFLAMMATION.  143 

Among  the  clinical  varieties  cf  chronic  ulcer  seen  in  surgical  practice  are  the 
varicose  ulcers,  erethistic,  perforating,  etc.  The  varicose  ulcer  is  found  on  the 
lower  or  middle  third  of  the  leg,  in  association  with  varicose  veins.  It  is  usually 
irregular,  but  after  a  time  becomes  more  round.  The  edges  of  the  varicose  ulcer 
are  undermined,  bluish,  pigmented,  and  show  slight  granulation;  when  older, 
the  edges  are  usually  callous.  The  discharge  from  a  chronic  ulcer  is,  as  a  rule, 
small  in  amount,  serous  in  character,  and  containing  tissue  debris  and  blood. 
About  large  varicose  ulcers  the  skin  is  usually  more  oedematous,  and  is  not 
rarely  deeply  pigmented.  Eczema  is  a  frequent  complication.  The  develop- 
ment of  granulation  tissue  is  slow  and  limited  in  extent.  Varicose  ulcers  may 
be  of  small  size  or  may  involve  the  greater  portion  of  the  limb.  They  are  often 
multiple. 

The  erethistic  ulcer  is  a  chronic  ulcer  found  over  the  inner  malleolus,  particu- 
larly in  women  who  have  varicose  veins  or  suffer  from  disorders  of  menstrua- 
tion. It  is  also  known  as  the  congested,  irritable,  or  painful  ulcer.  Beginning  as 
a  small  area  of  hyperemia  over  the  inner  malleolus,  it  gradually  increases  in  size, 
becomes  more  painful,  and  finally,  as  the  result  of  some  slight  injury,  develops 
into  an  ulcer  having  sharply  cut  edges  and  tightly  adherent  base.  The  skin 
about  the  ulcer  is  thickened,  pigmented,  and  adherent.  An  eczematous  condi- 
tion is  also  often  present.  These  ulcers  are  characterized  by  intense  pain,  due 
to  the  involvement  of  terminal  nerves  in  the  indurated  tissue  of  the  base  and 
edges.     They  are  very  slow  of  healing  and  often  return. 

The  perforating  ulcer  is  most  often  foiuid  on  the  sole  of  the  foot  over  the 
head  of  the  metatarsal  bones,  but  may  also  be  found  on  the  fingers  or  toes.  It 
occurs  chiefly  in  males  past  the  age  of  forty,  and  is  associated  with  constitu- 
tional conditions,  such  as  syphilis,  diabetes,  tabes  dorsalis,  arteriosclerosis,  etc. 
Sclerotic  changes  or  thrombosis  of  the  plantar  vessels  are  probably  the  direct 
etiological  factors  in  the  majority  of  cases.  The  perforating  ulcer  usually  be- 
gins as  a  small  callus  over  the  head  of  one  or  more  of  the  metatarsal  bones. 
Beneath  the  callus  the  abscess  develops.  As  there  is  usually  an  accompanying 
impairment  of  sensation,  the  condition  is  neglected  until  the  bone  has  become 
involved.  There  is  finally  formed  a  painless,  funnel-shaped  ulcer,  extending  to 
the  bone.  In  old  ulcers  of  this  kind  the  epithelium  may  extend  over  the  edges 
and  partly  or  entirely  cover  the  sides  of  the  funnel-shaped  depression.  The 
discharge  persists  as  a  scanty,  foul,  purulent  fluid,  containing  fragments  of  dead 
tissue  and  necrotic  bone. 

Chronic  ulcers  may  also  occur  in  gout  as  the  result  of  infection  of  tophi 
(gouty  ulcer).  Ulcers  of  the  skin  are  of  frequent  occurrence  in  diabetics  and 
show  a  tendency  to  spread  rather  than  to  heal.  In  syphilis  secondary  and  ter- 
tiary ulcerative  lesions  are  very  common  on  the  skin  and  mucous  membranes. 
They  may  be  superficial  or  deep,  and  arise  from  the  breaking  down  of  superficial 
or  deep  gummata.     They  are  often  serpiginous.     The  superficial  syphilitic  ulcers 


144  AMERICAN  PRACTICE  OF  SURGERY. 

are  usually  circular,  with  sharply  cut  edges  and  an  indurated  base  covered  with 
a  yellowish,  tenacious,  purulent  exudate.  The  deeper  ones  are  irregular,  with 
ragged,  undermined  edges  and  indurated,  sloughing  base.  Tuberculous  ulcers 
occur  in  the  skin  and  mucous  membranes,  being  of  more  frequent  occurrence  in 
the  latter  situation.  They  are  usually  secondary  to  chronic  tuberculous  proc- 
esses in  other  parts  of  the  body,  and  are  caused  by  the  caseation  of  local  tuber- 
cles with  secondary  infection.  The  edges  of  the  tuberculous  ulcers  are  usually 
elevated,  indurated,  and  not  undermined,  and  the  base  is  made  up  of  pale, 
caseous,  tuberculous  granulation  tissue.  The  tuberculous  ulcers  of  the  skin  ap- 
pear in  a  variety  of  forms  clinically,  and  have  been  designated  according  to  their 
most  prominent  characteristics  (vernicose,  indurated,  scrofidoderm,  etc.).  Acti- 
nomycosis, blastomycosis,  leprosy,  and  other  of  the  specific  infections  often  give 
rise  to  chronic  ulcerative  processes. 

More  or  less  atj^pical  formations  of  granulation  tissue  characterize  various 
specific  infections  (tuberculosis,  syphilis,  leprosy,  rhinoscleroma,  actinomycosis, 
blastomycosis,  glanders,  etc.).     They  form  nodular  or  diffuse  chronic  prolifera- 


FiG.  51. — Chron...  A.iw|M,,.  >..,,,,..  ■.  .1,.^,...^  in^.^wot^,  ^,  ^^^^^^^^^^^  ^^^^o^x;  c,  submucoaa; 
d,  muscularis;    e,  total  atrophy  of  mucosa.      (After  Ziegler.) 

tions  of  granulation  tissue,  which  are  classed  under  the  general  heading  of  in- 
fective granulomata.  As  a  rule,  they  possess  more  or  less  well-defined  character- 
istics of  structure  and  course,  that  permit  of  a  clinical  and  pathological  diagnosis. 
The  presence  of  the  etiological  factor  also  aids  in  the  differential  diagnosis.  The 
etiology  of  some  of  the  granulomata  is,  however,  still  imknown.  Various  clin- 
ical designations  are  applied  to  different  forms  of  granulomatous  conditions  (fun- 
gous granulations,  caro  luxurians,  etc.). 

Chronic  inflammations  characterized  by  marked  atrophy  of  the  parenchyma- 
tous tissues,  with  or  without  hyperplasia  of  the  connective  tissue,  are  usually 
called  atrophic.  (See  Fig.  51.)  They  occur  particularly  upon  the  mucous 
membranes  of  the  gastro-intestinal  tract  and  the  bladder,  and  in  the  liver  and 
kidneys.  In  the  gastro-intestinal  tract  the  epithelium  becomes  atrophic  as  the 
result  of  persistent  desquamation  or  necrosis,  the  connective  tissue  either  being 
unaffected  or  undergoing  necrosis  at  the  same  time.  It  rarely  shows  marked 
hyperplasia  in  this  location.  In  the  case  of  chronic  inflammations  of  the  liver 
and   kidneys,  the  atrophy  and   necrosis  are  accompanied  or  followed   by  a 


INFLAMMATION. 


145 


more  or  less  marked  hyperplasia  of  the  connective-tissue  stroma  (hepatic  cir- 
rhosis, contracted  kidney).  In  the  case  of  the  liver,  imperfect  attempts  at  re- 
generation of  liver  tissue  lead  to  a  hyperplasia  of  the  small  bile  ducts.  (See 
Fig.  52.)  Such  chronic  inflammations  are  known  as  productive,  indurative, 
hyperplastic,  etc. 

The  treatment  of  chronic  inflammations  is  both  constitutional  and  local. 


cf  a 


Fig.  52. — Connective-tissue  Hvperplaaia  and  Prol  ferat  on  of  Bile  Ducts  in  Chrome  Hepatitis  (al- 
cohol, hsematoxylin).  a.  aj,  Liver  lobules;  6,  hyperplastic  periportal  connective  tissue;  c,  old  bile 
ducts;  d,  newly  formed  bile  ducts;   e,  foci  of  small-celled  infiltration.      X  55.     (After  Ziegler.) 


The  general  condition  should  be  built  up  and  improved  by  proper  food,  hygiene, 
tonics,  etc.  The  cause  of  the  chronic  reaction  must  be  removed  or  inhibited 
when  possible.  Dead  tissue,  exudates,  foreign  bodies,  etc.,  should  be  sought  for 
and  removed.  The  general  indications  for  the  treatment  of  inflammatory  condi- 
tions— rest,  absolute  cleanliness,  asepsis,  etc. — should  be  met.  The  formation 
of  granulation  tissue  should  be  stimulated  in  the  various  ways  mentioned  above, 
plastic  operations  and  skin  grafting  carried  out  when  necessary,  and  the  promo- 
tion of  cicatrization  and  new  epithelial  growth  encouraged. 

VOL.  I. — 10 


THE   NATURE   AND   SIGNIFICANCE   OF   THE  VARIOUS 
DISTURBANCES    OF    NUTRITION    OBSERVED    IN 
CONNECTION  WITH  SURGICAL  DISEASES 
AND  CONDITIONS. 

By  ALBERT  GEORGE  NICHOLLS.  M.D.,  CM..  Montreal,  Canada.  ■ 
INTRODUCTORY. 

Before  we  can  attain  anj^thing  like  a  proper  compreliension  of  the  processes 
with  which  we  are  to  deal  in  the  following  pages,  we  must  have  some  knowledge 
of  the  general  principles  underlying  the  question  of  the  growth  and  development 
of  organized  structures.  All  those  physical  and  chemical  phenomena  included 
under  the  term  "nutrition,"  which  are  so  peculiarly  the  attributes  of  living  sul">- 
stance,  can  be  understood  only  by  a  reference  to  the  fundamental  properties  of 
protoplasm. 

Every  living  organism,  whether  animal  or  vegetable,  must  be  regarded  as 
being  composed  of  one  or  more  cells.  All  but  the  lowest  forms  of  life  are  essen- 
tially aggregations  of  cells  or  communities  of  primordial  units.  The  highest  and 
most  complicated  individuals,  whether  plant  or  animal,  are  composed  of  organs, 
these  of  tissues,  and  these  again  of  cells.  Ultimately,  then,  the  life  history  of 
any  individual  is  the  sum  total  of  the  life  histories  of  its  primitive  constituents. 
The  laws  which  govern  the  cell  are  those  which  govern  the  individiial  as  a  whole. 

Every  organized  being  begins  as  a  single  cell — the  fertilized  ovum.  This  cell 
is  peculiar,  in  that  it  represents  in  a  large  measure  the  characteristic  tendencies 
and  properties  of  the  parents.  What  it  will  become  depends  not  only  on  the 
specific  characters  implanted  in  it,  peculiarities  which  we  speak  of  as  inherited, 
but  also  on  the  influence  of  external  forces,  or  environment. 

The  first  step  in  the  development  of  the  complete  individual  is  the  division 
of  the  ovum.  The  resulting  cells  increase  in  size,  owing  to  the  influence  of  the 
pabulum  supplied,  and  finally  become  specialized  according  to  the  function 
which  they  have  eventually  to  perform.  We  can  thus  recognize  three  funda- 
mental attributes  of  primitive  cells:  (1)  Their  capacity  for  multiplication;  (2) 
their  power  to  increase  in  size,  and  (3)  their  tendency  toward  histological  differ- 
entiation. 

The  term  "growth"  implies  an  increase  in  size  of  the  organLsm.  This  in- 
crease is,  however,  not  true  growth,  unless  it  be  the  result  of  forces  inherent  in 
the  cells.    Enlargement  of  an  organ  or  tissue  may  be  due  to  the  deposit  within 


DISTURBANCES  OF  NUTRITION.  147 

it  of  some  product  of  degeneration,  such  as  fat,  or  to  a  variety  of  other  extrinsic 
causes.  This  is  not  growth.  The  growth  of  the  individual  is  the  expression  of 
the  growth  of  his  component  cells.  Growth,  then,  is  ultimately  dependent  on  an 
increase  in  the  size  of  single  cells  and  on  a  multiplication  of  their  numbers. 
Growth,  however,  implies  somewhat  more  than  this,  in  a  vague  way,  namely, 
the  power  of  the  cellular  elements  to  advance  in  the  scale  of  organization,  or  at 
least  not  to  retrograde. 

The  three  factors  just  referred  to — multiplication,  increase  in  size,  and  his- 
tological differentiation — so  far  as  the  organs  and  tissues  are  concerned,  operate 
in  harmony  and  to  some  extent  coincidently,  but  with  regard  to  the  individual 
cells  are  more  or  less  mutually  exclusive.  Cells  which  are  rapidly  dividing  are 
always  small,  since  they  have  no  resting  period  in  which  to  increase  their  bulk. 
The  finer  details  of  histological  differentiation  form  the  last  stage  in  the  devel- 
opment of  any  structure.  Conversely,  cells  which  are  highly  specialized  lose  to 
a  large  degree  the  power  of  multiplication,  or,  if  they  do  multiply,  must  first  re- 
vert to  a  more  primitive  condition. 

Development  is  in  a  sense  a  thing  apart  from  growth,  for  a  cell  or  tissue  may 
attain  practically  its  full  size,  in  proportion  to  the  individual  concerned,  with- 
out attaining  its  highest  degree  of  specialization.  Generally,  however,  we  employ 
the  term  "development"  in  a  broad  way,  to  include  not  only  growth  in  size, 
but  also  differentiation. 

The  capacity  for  growth  and  development  possessed  by  all  cells  and  tissues 
is  not  everywhere  manifested  in  the  same  degree.  Certain  structures  may 
take  years  to  attain  their  anatomical  and  functional  completeness,  while  others 
quickly  mature  and  as  quickly  retrograde. 

Let  us  examine  a  little  more  carefully  the  question  of  multiplication  of  cells 
and  the  increase  in  size  of  tissues. 

Believing,  as  we  do,  in  the  doctrine  that  every  cell  is  derived  from  a  previously 
existing  cell,  we  are  apt  to  go  somewhat  further  and  assume  that  one  kind  of  cell 
invariably  gives  rise  to  one  of  the  same  type;  for  example,  that  epithelium  gives 
rise  to  epithelium,  muscle  to  muscle,  nerve  cell  to  nerve  cell,  and  so  on.  This  is 
not  necessarily  so,  as  a  little  reflection  will  show  us.  The  mere  fact  that  a  sin- 
gle, undifferentiated  cell,  the  fertilized  ovum,  is  the  precursor  of  all  the  cells  of 
the  body  and  gives  rise  to  the  most  highly  specialized  structures,  such  as  the 
retina,  might  have  prepared  us  for  something  different.  As  a  matter  of  fact, 
when  we  study  growing  tissues  we  see  that  certain  cells  alone  are  actively  divid- 
ing or  are  actively  proliferative,  while  others  do  not  divide,  but  assume  other 
special  functions.  If  we  take  the  case  of  a  growing  plant,  we  find  that  at  the  tip 
of  each  stem  or  rootlet  there  is  a  mass  of  cells  of  embryonic  type,  which  are  un- 
dergoing rapid  division.  Development  takes  place  in  a  very  peculiar  way.  At 
the  extreme  end  of  the  stem  is  a  cell  or  group  of  cells,  that  always  divide  by 
transverse  fission  into  a  distal  and  a  proximal  daughter  cell  or  cells.    The  distal 


148  AIVIERICAX  PRACTICE  OF  SraGERY. 

daughter  cell  at  the  tip  alwaj-s  retains  its  embryonic  characters  and  keeps  on 
dividing  in  the  same  manner.  Thus,  the  original  proximal  daughter  cell  becomes 
separated  from  the  tip  of  the  stem  by  successive  divisions  of  the  apical  cell  or 
cluster  of  cells.  The  distal  cells  never  do  anything  but  divide.  The  proximal 
ones,  however,  have  another  destiny.  They  eventually  cease  multiplying,  be- 
come larger  and  vacuolated,  and  eventuallj'  assume  the  characters  of  the  cells 
of  the  tissues  to  which  they  belong.  In  other  words,  they  become  differentiated. 
Thus  we  see  that  certain  cells  are  specialized  for  multiplication,  others  for 
growth  and  for  histological  differentiation.  The  same  thing  holds  in  connection 
■n-ith  animal  life.  The  more  highly  differentiated  cells  of  a  tissue  do  not  give 
rise  directh'  and  by  diAosion  to  other  cells  of  the  same  tj-pe,  but  in  each  tissue 
there  are  undifferentiated  cells — mother  cells,  or  embryonic  cells — which  have 
the  special  power  of  proliferating;  and  it  is  the  daughter  cells,  derived  from 
these,  that  reach  the  highest  anatomical  and  functional  perfection. 

Proofs  of  this  might  be  multiplied.  As  a  consequence,  we  may  lay  down  the 
following  general  principles:  1.  That  fully  differentiated  cells  of  a  tissue  never 
give  rise  directty  to  cells  of  the  same  highly  specialized  tj'pe.  2.  That  in  all 
tissues  there  are  certain  "embryonic"  or  undifferentiated  cells,  whose  special 
function  is  to  di^dde,  and  that  the  daughter  cells  derived  from  these  are  the  ones 
which  subsequentlj'  attain  the  higher  planes  of  development.  3.  The  more 
highly  specialized  the  cell,  the  more  difficult  it  is  for  it  to  reproduce  its  kind ;  con- 
versely, the  more  primitive  the  type  of  the  cell,  the  more  easily  will  it  prolifer- 
ate. These  general  laws,  which  hold  good  in  regard  to  the  natm-al  growth  and 
development  of  the  organism,  are  equalh'  true  in  connection  with  pathological 
processes.  Injured  or  lost  parts  are  restored  to  the  normal  in  accordance  ■nith 
the  same  laws  which  governed  their  formation  in  the  fu'st  instance.  As  the 
higher  forms  of  cell  are  derived  from  the  lower,  so  must  they  revert  to  a  more 
embryonic  condition  before  they  can  midergo  proliferation. 

Finally,  as  we  have  tliree  fimdamental  properties  of  protoplasm,  so  we  have 
three  methods  by  which  its  A-ital  energies  are  manifested — assimilation,  nutri- 
tion, and  reproduction.    Any  interference  with  these  \\i\\  cause  disease. 

HYPERTROPHY. 

In  a  general  way,  h5^ertrophy  may  be  defined  as  an  increase  in  the  sub- 
stance of  a  tissue  or  organ,  due  to  an  increase  in  the  nmiiber  or  in  the  size  of  its 
component  cells,  or  to  a  combination  of  both  these  conditions,  without  any  other 
alteration  of  structure.  Like  many  other  definitions,  this  one  needs  to  be 
defined. 

As  we  have  seen,  growth  consists  in  the  increase  of  tissue  by  the  addition 
of  new  material  of  the  same  natiue  as  that  already  existing.  The  essential  char- 
acter of  the  part  is  not  altered,  but  its  bulk  is  increased,  and  it  is  therefore  en- 


DISTURBANCES  OF  NUTRITION.  149 

abled  to  perform  more  work  than  it  had  previously  been  doing.  Up  to  a  certain 
point  development  and  growth  go  hand-in-hand.  Wlren  the  time  comes  that 
all  the  necessary  parts  of  a  structure  are  complete,  development  ceases,  although 
growth  may  for  a  time  continue  until  the  perfect  stature  and  proportion  of  the 
body  are  attained.  It  is  not,  however,  possible  to  fix  the  point  at  which  either  de- 
velopment or  growth  ceases,  for  in  this  particular  different  organs  and  structures 
have  their  own  peculiarities,  and  much  depends  on  personal  idiosyncrasy  and 
the  condition  of  the  bodily  health.  Some  organs,  like  the  thymus,  reach  their 
full  perfection  during  childhood,  and  early  atrophy  and  disappear;  others,  like 
the  heart  and  arteries,  have  been  shown  to  go  on  receiving  increments  of  sub- 
stance and  power  until  advanced  years.  Much,  however,  depends  upon  circum- 
stances. If  the  bodily  health  be  robust  and  the  organ  in  question  be  regularly 
and  fully  exercised,  then  growth  will  continue,  or,  at  all  events,  the  organ  will 
not  waste.  Any  addition  to  the  amoimt  of  work  demanded  of  any  organ  will  re- 
sult in  an  increase  in  its  size.  To  a  certain  extent  this  is  desirable  and  can  hardly 
be  regarded  as  an  evidence  of  disease.  In  fact,  it  is  often  difficult  to  draw  the 
line  between  what  may  be  termed  physiological  hypertrophies  and  the  patho- 
logical overgrowths,  for  both  are  essentially  conservative  processes,  tending  to 
maintain  the  nutrition  and  function  of  the  part  in  the  highest  possible  efficiency. 
It  would  appear,  too,  as  if  all  organs  possessed,  though  in  varying  measure,  a 
certain  reserve  power  of  growth  and  development,  which  they  are  able  to  put 
into  action  in  case  of  necessity.    In  this  way  the  extra  demand  is  compensated. 

The  orderly  and  natural  progression  of  the  metabolic  processes,  which  is 
the  indication  of  health,  is  dependent  upon  the  correlation  of  several  factors, 
the  vascular  supply  of  the  part,  its  innervation,  and  the  mutual  relationship 
with  other  structures.  There  is,  so  to  speak,  a  constant  effort  toward  an 
equilibrium.  In  the  case  of  overgrowth  the  same  general  laws  are  at  work. 
The  possibility  of  the  occurrence  of  hypertrophy,  and  its  efficiency  when  it  has 
arisen,  depend  essentially  upon  the  state  of  nutrition  of  the  affected  part. 
This  implies  an  adequate  vascular  and  nervous  supply.  The  blood-vessels  must 
therefore  enlarge  and  the  trophic  centres  be  correspondingly  active.  The  blood 
also  must  be  of  good  quality.  Once  the  reserve  power  of  the  part  is  exhausted, 
not  only  does  the  process  of  hypertrophy  cease,  but  degeneration  and  atrophy 
take  its  place,  resulting  in  functional  inadequacy  of  the  structures  concerned. 
Consequently,  as  we  would  expect,  we  get  the  most  extreme  examples  of  hyper- 
trophy in  the  young  and  robust,  while,  on  the  other  hand,  in  the  aged  and  de- 
bilitated the  ordinary  causes  will  fail  more  or  less  completely  to  produce  it. 

Not  only,  however,  does  the  term  "hypertrophy"  connote  an  increase  in 
size,  but  there  may  be,  in  addition,  a  formation  of  new  tissue.  Thus,  in  the  hy- 
pertrophied  heart  the  muscle  fibres  are  more  numerous,  stronger,  and  more 
highly  colored.  In  the  liver  of  atrophic  cirrhosis,  while  many  of  the  parenchym- 
atous cells  are  wasted,  fatty,  and  degenerated,  new  ones  are  formed,  which  are 


150  AMERICAN  PRACTICE  OF  SURGERY. 

almost  gigantic,  having  large,  deeply-staining  nuclei.  In  the  pregnant  uterus 
new  and  relatively  large  and  powerful  fibres  are  produced.  It  is  usual,  therefore, 
to  recognize  two  forms  of  hypertrophy.  Where  there  is  a  simple  increase  in  the 
size  of  the  cells  composing  the  part,  we  speak  of  quantitative  or  true  hypertrophij; 
if  there  be  an  increase  in  the  number  of  the  cells,  we  speak  of  numerical  hyper- 
trophy or  hyperplasia.    As  a  rule,  both  conditions  are  combined. 

According  to  the  nature  of  the  cause  at  work,  hypertrophy  may  be  tempo- 
rary or  permanent.  Many  of  the  temporary  hypertrophies  are  physiological  in 
their  nature,  as,  for  instance,  the  enlargement  of  the  uterus  during  gestation, 
the  enlargement  of  the  muscles  from  increased  exercise,  the  production  of  new 
and  active  acini  in  the  breast  during  pregnancy  as  a  preparation  for  lactation. 
Should  the  cause  persist  or  from  its  nature  be  irremovable,  temporary  hyper- 
trophy becomes  permanent  and  may  lead  to  important  consequences. 

As  a  rule,  it  is  possible  to  discover  some  reason  for  the  production  of  hyper- 
trophy in  a  given  case.  There  are,  however,  instances  which  are  more  or  less 
obscure.  Such  are  the  hypertrophies  which  are  occasionally  seen  in  the  thyroid 
and  thymus  glands,  the  spleen,  tonsils,  and  prostate,  and  in  warts  and  polypi. 
Some,  possibly,  may  have  an  inflammatory  basis,  while  in  the  case  of  the  duct- 
less glands  there  may  be  some  disturbance  in  a  correlated  organ.  But  more  than 
this  we  can  hardly  say,  in  view  of  the  present  state  of  our  knowledge,  or,  rather, 
want  of  knowledge.  We  must  for  the  time  being  be  content  to  recognize  cer- 
tain hypertrophies,  which  have  affinities,  on  the  one  hand,  with  inflammation, 
and,  on  the  other,  with  neoplastic  growth. 

The  anatomical  changes  peculiar  to  hypertrophy  are  usually,  though  by  no 
means  invariably,  manifested  by  an  increase  in  the  size  and  weight  of  the  af- 
fected structure.  Mere  increase  in  weight  does  not,  however,  constitute  hyper- 
trophy. For  example,  the  heart  may  be  enormously  enlarged  in  point  of  its  ex- 
ternal configuration,  owing  to  dilatation  of  its  cavities  or  from  a  deposit  of  fat 
upon  its  surface;  the  liver  m.ay  be  enlarged  from  hypertemia  or  inflammatory 
infiltration.  Conversely,  the  heart  may  present  no  external  evidences  of  hj'per- 
trophy,  in  that  its  bulk  is  not  increased,  and  yet  it  may  be  truly  hyper trophied. 
This  occurs  in  the  so-called  "concentric"  hypertrophy,  in  which  the  enlarged 
muscle  has  encroached  upon  the  cavities.  Before,  then,  either  increased  size  or 
weight  of  an  organ  can  be  taken  as  an  evidence  of  hypertrophy,  we  must  make 
sure  that  this  increase  is  not  due  to  any  cause  but  the  increase  in  size  or  number 
of  the  pre-existing  cells  of  the  part.  This,  as  a  rule,  can  be  determined  only  by 
a  careful  microscopical  examination. 

Histologically,  true  hypertrophy  is  indicated  by  an  increase  in  the  bulk  of 
the  individual  cells.  The  nucleus  is  enlarged,  often  altered  in  shape,  and  stains 
more  intensely  than  usual.  Thus,  in  the  case  of  the  heart  muscle,  the  nucleus  of 
the  fibre  is  enlarged  and  more  obtuse  at  the  poles  than  normal.  Nuclear  division 
is  not  infrequent.    The  cell  body  is  also  enlarged,  and  the  cytoplasm  shows  an 


DISTURBANCES  OF  NUTRITION.  151 

increased  affinity  for  stains,  such  as  eosin,  being  of  greater  intensity  and  bril- 
liancy than  that  of  similar  cells  under  normal  conditions.  In  the  case  of  pig- 
mented cells,  such  as  those  of  the  muscle,  the  pigment  appears  to  be  increased. 
These  minute  changes  can  be  properly  appreciated  only  by  a  comparison  with 
the  normal  condition  of  things  and  by  accurate  measurements  of  the  cells,  al- 
though an  expert  microscopist  will  usually  be  able  to  reach  fairly  correct  con- 
clusions without  such  assistance. 

Rarely  or  never  do  all  the  cells  of  an  organ  or  tissue  manifest  the  same  degree 
of  hypertrophy  throughout.  For,  paradoxical  as  it  may  seem,  hypertrophy 
and  atrophy  often  go  together.  The  cells  may  be  increased  in  size  but  dimin- 
ished in  number,  or,  conversely,  hyperplasia  may  be  accompanied  by  a  decrease 
in  bulk  of  the  individual  elements. 

Granting,  then,  a  natural  tendency  of  cells  toward  growth,  which,  under  cer- 
tain circumstances,  may  be  in  excess  of  the  normal,  we  find  that  the  causes 
at  work  in  the  production  of  hypertrophy  are  either  intrinsic  or  extrinsic.  In 
the  former  case  the  abnormal  tendencies  to  cell  growth  and  multiplication  ap- 
pear to  be  inherent  in  the  cells,  the  result  of  some  peculiarity  in  the  germinal 
cells  or  of  germ  variation.  Here  the  anomaly  is  present  at  birth  or  makes  its 
appearance  comparatively  soon  after.  Extrinsic  hypertrophy  is  usually  the  re- 
sult of  increased  nutrition  and  excessive  demand  upon  the  function  of  an  organ, 
or  of  a  disturbance  of  the  equilibrium  that  ought  to  subsist  between  anabolism 
and  katabolism. 

Intrinsic  Hsrpertrophy. — This  is  congenital  or  else  appears  shortly  after  birth. 
As  a  rule,  the  internal  viscera  are  not  involved,  unless  we  accept  certain  obscure 
enlargements  of  the  brain,  thymus,  spleen,  and  Ijonph  nodes  as  of  congenital 
origin.  The  condition  may  be  universal  or  partial.  A  number  of  organs  and 
tissues  may  be  affected.  Hypertrophy  of  the  epidermis  gives  rise  to  the  condi- 
tion known  as  congenital  ichthyosis.  Increase  in  the  amount  of  hair,  or  its  ap- 
pearance on  parts  of  the  body  that  are  normally  destitute  of  it,  is  called  hyper- 
trichosis. Enlargement  of  the  nails  is  hyperonychia.  The  amount  of  fat  may  be 
excessive — lipomatosis  or  obesity.  Elephantiasis  is  a  term  used  somewhat  loosely 
to  designate  a  number  of  conditions  which  have  this  in  common,  that  the  af- 
fected part  is  enlarged  (see  Fig.  53).  The  tropical  form  of  elephantiasis  is  not 
a  true  hypertrophy,  but  is  more  akin  to  inflammation.  The  enlargement  is  due 
to  the  obstruction  of  the  lymphatics,  with  secondary  hyperplasia  of  the  connec- 
tive tissue.  There  are  a  number  of  congenital  conditions,  however — as,  for  in- 
stance, certain  nsevi  and  enlargements  of  the  face,  lips  (macrocheilia) ,  and  tongue 
macroglossia) — which  appear  to  depend  on  some  obstruction  of  the  lymphatics 
and  blood-vessels,  with,  in  some  cases,  apparently  actual  new-formation  of  ves- 
sels, which  possibly  may  be  included  under  hypertrophy. 

Perhaps  the  best  example  of  congenital  hypertrophy  is  gigantism.  This  may 
affect  the  body  as  a  whole — bones,  muscles,  skin,  nerves,  vessels,  and  internal 


152  ^LAIERIC.IN  PRACTICE  OF  SLTIGERY. 

organs  {general    gigantism) — or  some  particular  organ  or  member  (partial  gi- 
gantism). 

In  true  or  essential  gigantism  the  indi-\-iduaI  affected  differs  in  no  respect 
from  the  normal,  save  in  the  one  particular  of  size  and  \reight.  In  addition  to  ex- 
cessive size  and  weight,  there  are  great  strength  and  perfect  proportion,  together 


Fig.  53. — Elepliantiasis  of  the  Leg ;  Enormous  Enlargement  of  the  Limb,  vrith  Ichthyosis.      {Patho- 
logical yiuseuni,  McGill  University.) 

with  ordinarj'^  intelligence.  Such  giants  are  examples  of  the  so-called  "athletic" 
liabit  of  bod}-,  and  represent  the  hmnan  body  carried  to  its  highest  power  in 
point  of  structme.  Cases  of  this  kind  have  no  doubt  existed,  but  are  excessively 
rare.  As  a  rule,  however,  giants  present  the  unmistakable  stigmata  of  defect. 
The  increase  in  height  is  due  mainly  to  excess  in  the  long  bones;    the  head 


DISTURBANCES  OF  NUTRITION. 


153 


is  proportionately  small;   there  are  evidences  of  infantilism,  knock-knee,  and 
genital  inadequacy;  and,  finally,  physical  and  mental  weakness. 

Besides  this  form  of  general  gigantism,  or,  as  it  might  perhaps  be  more  cor- 
rectly styled,  macrogenesy,  there  are  certain  less  extreme  manifestations  of  the 
tendency  in  the  form  of  local  hypertrophies,  which  are  midoubtedly  of  develop- 
mental origin.  Such  are  the  forms  which  involve  the  head  or  extremities.  In 
leontiasis  ossea  there  is  an  excessive  and  remarkable  deformity  of  the  bones  of 
the  face  and  skull,  which  appears  to  be  essentially  a  diffuse  hyperostosis.  Local 
gigantism  in  children  is  especially  common  in  the  upper  limbs,  and  may  be  uni- 
lateral or  bilateral.  Hemihypertrophy  of  the  body  has  also  been  described. 
One  or  more  digits  may  be  affected  (macrodactylia) ,  or  a  whole  limb.  Apart  from 
these  instances  of  local  gigantism,  which  are  characterized  mainly  by  an  increase 
in  the  bulk  of  the  part,  there  are  certain  other  forms  of  numerical  increase, 


Fig.  54. — Cross  Section  of  the  Heart,  to  Show  Hypertrophy  of  the  Walls.      The  cause ;  increased 
peripheral  tension.      (Pathological  Museum,  McGill  University.) 

which  some  authorities  would  include  under  the  heading  "gigantism."  Such 
are  polydactylism,  accessory  ribs,  and  supernumerary  organs.  Tliese  peculiarities 
are  occasionally  associated  with  general  gigantism. 

Extrinsic  Hypertrophy. — Hypertrophies  which  are  not  dependent  on  some 
constitutional  and  inherent  peculiarity,  but  are  the  result  of  some  external 
cause,  are  called  extrinsic  hypertrophies.  They  are,  in  other  words,  acquired. 
It  is  undoubtedly  somewhat  difficult,  if  not  impossible,  in  many  cases  to  draw 
the  line  between  the  congenital  and  the  acquired  forms;  for  some  cases,  which 
closely  resemble  the  congenital  varieties,  may  on  occasion  result  from  external 
causes.  Such  are  certain  forms  of  ichthyosis  and  elephantiasis.  It  is  not  impos- 
sible that  these  external  causes  may  have,  in  some  cases,  been  operative  diuing 


154  AMERICAN  PRACTICE  OF  SURGERY. 

intra-uterine  existence.  It  is  probable,  moreover,  that  in  many  instances,  even 
where  the  condition  is  evidently  due  to  external  influences,  there  is  some  inher- 
ited tendency  to  overgrowth  of  tissue  as  well.  As  in  the  case  of  cancer,  there 
must  be  some  predisposition  of  the  cells  before  the  exciting  cause  can  wake  up 
the  latent  activity. 

Hypertrophies  not  dependent  on  a  constitutional  idiosyncrasy  are  always  the 
result  of  an  increased  demand  upon  the  functional  activity  of  the  part  or  of  some 
disturbance  of  the  balance  which  ought  to  exist  between  waste  and  repair.  In 
the  majority  of  instances  it  is  the  former.  We  may  recognize  the  following  vari- 
eties, to  be  more  precise,  namely : 

(1)  Hypertrophy  from  increased  functional  activity. 

(2)  H3'pertrophy  from  lessened  wear. 

(3)  Hypertrophy  from  removal  of  pressure. 

(4)  Hypertrophy  from  failure  of  involution. 

(5)  Hypertrophy  from  increased  nutrition. 

(6)  Hypertrophy  from  chronic  irritation. 

(7)  H3'pertrophy  from  errors  of  metabolism. 

(8)  Hypertrophy  of  neuropathic  origin. 

Hypertrophy  from  increased  work  usually  affects  the  muscles  and  glands, 
less  often  other  tissues.  In  some  unexplained  way  the  unwonted  physi- 
cal and  chemical  condition  of  the  muscle  or  gland  cell  leads  to  excessive  cell 
growth. 

Perhaps  the  best  example  of  this  form,  which  has  been  called  labor  or  fiinc- 
tional  hypertrophy,  is  to  be  found  in  the  heart.  Increased  peripheral  vascular 
tension,  certain  renal  and  pulmonary  diseases  interfering  with  the  circulation, 
and  obstructive  valvular  affections  of  the  heart  itself,  lead  to  overgrowth  of  that 
portion  which  feels  the  strain  most,  and  eventually  to  involvement  of  the  whole 
organ.  (See  Fig.  54.)  Again,  as  Thoma  has  shown,  increased  arterial  tension 
produces  hypertrophy  of  the  middle  coats  of  the  arteries. 

It  is  a  matter  of  common  observation  that  increased  muscular  exercise  results 
in  increased  bulk  of  the  muscles.  This  is  particularly  well  seen  in  the  case  of 
laborers,  in  whom  certain  muscle  bundles  or  groups  are  often  picked  out.  It  is 
believed  that  the  individual  fibres  increase  not  only  in  length  and  thickness, 
but  also  in  number.  Many  interesting  examples  are  also  to  be  found  in  the  case 
of  the  involuntary  muscles.  Thus,  the  uterus  may  be  considerably  enlarged  when 
the  seat  of  fibroid  tumors  or  of  hsematometra.  Any  obstruction  in  the  alimentary 
tract — oesophagus,  stomach,  or  intestines, — whether  due  to  foreign  bodies,  tumors, 
adhesions,  or  strictures,  will  inevitably  lead  to  overgrowth  of  the  tissues  above 
the  obstructed  point.  The  same  thing  occurs  in  the  urinary  bladder  in  cases  of 
enlarged  prostate,  stricture,  or  calculi.  In  these  hollow  organs  the  walls  often  be- 
come enormously  ballooned  out,  but  with  this  there  is  always  an  increase  in  sub- 
stance.   This  affects  chiefly  the  muscular  layers,  but  the  mucous  membrane  must 


DISTURBANCES  OF  NUTRITION.  155 

also  enlarge  to  accommodate  itself  to  the  changed  order  of  things.  In  all  such 
cases  there  is  an  attempt  on  the  part  of  nature  to  overcome  by  muscular  force  the 
hinderance  to  the  proper  performance  of  function.  It  should,  however,  be  pointed 
out  that  mere  frequency  in  the  performance  of  a  muscular  act  is  not,  so  far  as  we 
are  aware,  competent  in  itself  to  produce  hypertrophy.  The  heart  may,  for  ex- 
ample, beat  more  rapidly  than  normal  for  years  without  increasing  in  bulk  and 
power.  The  action  must  at  the  same  time  be  forcible.  This  is  well  illustrated  in 
the  case  of  mechanics.  The  hand  muscles  in  those  who  use  speed  are  usually  not 
so  large  as  in  those  who  exert  great  muscular  force.  The  same  thing  can  be  seen 
in  the  case  of  sprinters,  athletes,  greyhounds,  and  racehorses,  who  not  infre- 
quently suffer  from  hypertrophied  heart.  In  all,  not  only  is  the  heart's  action 
increased  in  rapidity,  but  it  is  excessively  forcible.  The  blood  pressure  is  tem- 
porarily raised  during  the  great  effort,  but  the  rapidly-acting  muscles  demand 
an  increased  supply  of  nourishment.  The  first  effect  of  this  is  dilatation  of  the 
heart,  which  subsides  after  the  extra  call  has  ceased,  but,  when  such  demands 
are  repeated,  finally  gives  place  to  hypertrophy. 

Another  form  of  overwork  is  seen  in  some  of  the  secretory  organs.  Of  all 
glands,  the  kidney  and  the  liver  appear  to  have  the  greatest  powers  of  cell  growth 
and  proliferation.  In  diabetics  and  those  who  drink  to  excess  the  kidneys  may 
be  considerably  enlarged.  Hypertrophy  of  the  liver  as  a  whole  is  rare,  but  the 
liver  possesses  considerable  powers  of  regeneration,  as  may  be  seen  in  cases 
where  portions  of  the  liver  have  been  removed.  The  original  weight,  though 
not  the  shape,  is  quickly  restored.  Hypertrophy  of  single  cells  or  small  groups 
of  cells  is,  however,  by  no  means  uncommon.  This  is  met  with  even  in  such 
acute  conditions  as  acute  yellow  atrophy,  and  is  a  constant  accompaniment  of 
chronic  passive  congestion  and  all  forms  of  cirrhosis.  The  "hobnails"  of  the 
gin-drinker's  liver  are  not  due,  as  is  so  often  taught,  to  the  contraction  of  the 
fibrous  bands,  but  to  an  actual  hypertrophy  and  hyperplasia  of  the  parenchym- 
atous cells. 

Inasmuch  as  all  such  cases  of  cell  proliferation  are  attempts  on  the  part  of 
the  organism  to  make  good  or  compensate  some  abnormal  condition,  these  hy- 
pertrophies are  frequently  termed  "compensatory."  Many  of  them,  as  we  have 
seen,  are  the  result  of  disease  in  some  part  of  the  body  more  or  less  remote  from 
the  organ  or  tissue  affected.  An  important  class  of  cases  is  that  which  might  be 
termed  "complemental."  Such  are  the  hypertrophies  which  occur  in  one  or 
other  of  a  pair  of  organs  or  in  structures  that  are  accustomed  to  work  together. 
Should,  for  instance,  one  kidney  fail  to  be  properly  developed  from  agenesia  or 
hypoplasia,  or  should  it  be  at  any  time  removed,  or,  again,  be  the  subject  of 
some  disease  that  materially  interferes  with  its  function,  the  remaining  kidney 
will  attempt  to  overtake  the  increased  work,  and,  as  a  consequence,  will  hyper- 
trophy. In  such  cases  not  only  may  there  be  a  hypertrophy  of  the  pre-existing 
structures,  but,  in  young  individuals  at  least,  there  may  be  an  actual  new  for- 


156  A]\IERIC.4X  PRACTICE  OF  SI'EGERY. 

mation  of  glomeruli  and  tubules.  The  enlargement  of  the  good  kidney  is  usually 
much  greater  in  the  case  of  congenital  deficiencj^  of  the  organ  than  in  cases  of 
acquired  disease — a  circumstance  which  goes  to  support  the  principle  already 
indicated,  that  the  power  of  regeneration  is  greater  in  young  than  in  old  cells. 
Smiilarly,  destruction  of  one  suprarenal  may  be  followed  by  h3rpertrophy  of  the 
other,  and  agenesia  or  hypoplasia  of  one  lung  may  be  followed  by  hypertrophy 
of  the  remaining  organ.  In  older  persons,  however,  where  one  lung  is  the  sub- 
ject of  disease,  the  compensation  takes  the  form  of  emphysema  rather  than  that 
of  true  hypertrophy,  inasmuch  as  the  air  sacs  dilate — a  condition  which  results 
in  atrophy  of  the  alveolar  walls.  Here,  again,  increase  in  bulk  does  not  indicate 
hypertroph}'. 

The  power  of  compensation,  which  is  so  strikmgly  exemplified  in  the  process 
of  hypertrophy,  is  beautifully  illustrated  in  certain  affections  of  the  lower  ex- 
tremit}^  When,  for  instance,  the  tibia  is  weakened  from  rarefaction  or  necrosis 
or  from  a  badly  repaired  fracture,  the  fibula  becomes  unduly  thick  and  strong  in 
order  to  meet  the  increased  strain. 

A  second  and  perhaps  the  more  interesting  class  of  cases  has  to  do  with  or- 
gans which  are  fmictionally  complemental.  The  most  notable  instance  of  this  is 
found  in  connection  with  the  thyroid  gland  and  pituitary  body,  which  are  now 
generally  believed  to  be  closely  related  and  of  great  unportance  in  the  bodily 
metabolism.  Loss  of  function  of  the  thjToid,  as  from  disease  or  the  removal  of 
a  portion  of  the  gland,  is  followed  not  only  by  hj^Dcrtrophy  of  the  remaining 
part,  but  by  overgrowth  of  the  pituitary.  Again,  as  Warthin  has  recently 
sho^Ti,  in  cases  of  pernicious  anaemia  and  leukaemia,  where  the  function  of  the 
bone-marrow  appears  to  be  impaired,  the  haemol}Tnph  glands  become  enlarged 
and  their  structure  alters  mitil  it  comes  to  resemble  that  of  the  spleen  or  bone- 
marrow. 

Tissues  which  are  normally  the  subjects  of  constant  wear  often  attam  an  ab- 
normal size  imder  conditions  where  the  loss  of  substance  ceases.  This  generally 
occitrs  in  connection  with  the  teeth,  nails,  and  skm.  The  teeth  are  normally 
kept  at  a  constant  length,  owing  to  the  attrition  which  takes  place  in  conse- 
quence of  the  function  of  mastication.  If  the  teeth  do  not  properly  approxi- 
mate, as  in  cases  where  certain  teeth  are  movable  or  have  fallen  out,  or,  again, 
in  fracttires  of  the  jaw,  the  unopposed  teeth  gradually  elongate  aiid  may  even 
form  tusks.  This  is  seen  normalh^  in  certain  animals,  like  the  wild  boar,  and  is 
found  occasionalh'  in  rodents  under  the  circumstances  mentioned.  (See  Fig.  55.) 
The  tendency  for  such  teeth  to  grow  in  a  circle  is  explained  bj'  the  fact  that  the 
enamel  of  the  posterior  aspect  is  more  yielding  than  that  of  the  anterior.  In 
bedridden  patients,  in  whom  the  ordinarj'  wear  is  prevented,  the  nails  often  be- 
come thickened,  elongated,  and  deformed.  (See  Fig.  56.)  Failure  to  cut  the 
nails  is  followed  b}'  a  similar  elongation,  as  ma}^  be  seen  in  the  nails  of  the 
Chinese  exquisite  or  of  the  Hindu  fakir.    An  analogous  overgrowth  is  occasion- 


DISTURBANCES  OF  NUTRITION. 


157 


ally  met  with  in  the  beak  of  birds  and  in  the  formation  of  horny  pads  on  the 
feet  of  animals. 

Hypertrophy  also  results  from  the  removal  of  pressure,  or,  to  put  it  some- 
what differently,  from  a  disturbance  of  the  mutual  tension  which  exists  between 
tissues.  If  from  any  cause  the  brain  lags  behind  in  its  development,  the  skull 
remains  small  in  order  to  accommodate  itself  to  the  abnormal  condition  of 
things  (microcephaly).  This,  however,  occurs  only  during  the  developmental 
period  of  life.  At  a  later  time — that  is,  after  adult  age  has  been  attained — any 
loss  of  substance  of  the  brain,  as  from  atrophy  or  disease,  is  compensated  in 
another  way.  Theoretically,  the  wasting  of  the  brain  would  leave  a  space 
between  the  dura  and  the  calvarium.  But,  as  "nature  abhors  a  vacuum,"  the 
space  is  filled  up  either  with 
watery  fluid  (hydrops  ex  vacuo) 
or  by  an  overgrowth  of  the 
cranial  vault.  The  diploe  and 
the  inner  table  are  reconstructed 
and  enlarged,  so  that  the  skull- 
cap  may  become  greatly 
thickened,  although  its  external 
appearance  may  remain  un- 
altered. Such  hypertrophy  is 
usually  most  marked  in  the 
neighborhood  of  the  primitive 
centres  of  ossification  of  the 
cranial  bones — a  fact  which 
illustrates  in  an  interesting  way 
the  uniformity  of  the  law  which 

governs  growth  and  development,  whether  in  normal  or  in  diseased  conditions. 
An  analogous  condition  is  the  overgrowth  of  the  fat  which  takes  place  about  a 
contracted  or  atrophied  kidney,  the  loss  of  substance  being  thus,  though  in  an 
inadequate  fashion  so  far  as  fimction  is  concerned,  made  good. 

Failure  of  involution  to  take  place  results  sometimes  in  a  permanent  enlarge- 
ment of  the  affected  organ.  The  thymus,  which  attains  its  full  growth  and  per- 
fection about  the  second  year  of  life,  from  that  time  on  begins  to  atrophy,  until 
at  puberty  but  little  of  it  is  left,  and  about  the  thirtieth  year  it  is  represented 
merely  by  fat  and  connective  tissue  and  some  scanty  remains.  Occasionally  the 
thymus,  in  its  perfect  structure,  may  persist  even  after  puberty.  Why  this  pe- 
culiarity occurs  and  what  may  be  its  significance  are  still  matters  for  inquiry. 
Another  and  a  common  form  is  the  subinvolution  of  the  uterus,  which  some- 
times occurs  after  delivery. 

It  has  been  laid  down  as  a  general  principle  that  before  growth  or  over- 
growth of  a  tissue  can  occur  there  mvist  be  an  adequate  supply  of  healthy  blood. 


Fig.  So. — Head  of  a  Woodehuek,  showing  Hypertrophy 
of  the  Incisor  Teeth  from  Lessened  Wear.  (Pathological 
Museum,  McGill  University.) 


158 


AMERICAN  PRACTICE  OF  SURGERY. 


For  only  by  means  of  an  active  blood  supply  can  the  nutrition  of  a  part  be  kept 
up.  If  we  examine  a  hypertrophied  tissue  we  generally  find  that  the  blood-ves- 
sels supplying  it  are  also  enlarged.  This  is  probably  in  most  cases  a  secondary 
phenomenon.    Here,  as  in  other  spheres,  the  demand  creates  the  supply.    But 

the  converse  is  equally  true, 
that  an  excessive  blood  supply 
frequently  leads  to  hypertrophy. 
The  enlargement  of  the  vol- 
untary muscles  from  exercise 
already  referred  to,  is  not.  al- 
together due  to  increased  func- 
tion, but  in  a  large  measure  to 
the  increased  degree  of  nutrition 
which  this  implies.  For,  from 
the  very  nature  of  the  mechani- 
cal action,  the  heart  is  stimu- 
lated, an  increased  amount  of 
blood  is  determined  to  the  part, 
,•11  id,  while  the  wear  and  tear  are 
greater  than  normal,  the  poison- 
ous products  of  metabolism  are 
more  rapidly  eliminated.  Apart, 
however,  from  mechanical 
action,  many  interesting  examples  may  be  cited  to  show  the  influence  of  a 
mere  increase  in  the  amount  of  blood  reaching  a  certain  part.  The  "  clubbed 
fingers"  so  often  seen  in  chronic  pulmonary  and  cardiac  affections  seem  to  be  in 
the  main  the  result  of  venous  hyperemia.  A  more  marked  enlargement  affect- 
ing both  bones  and  soft  tissues  is  met  with  in  the  so-called  hypertrophic  pul- 
monary osteoarthropathy  of  Marie.  The  cause  here  is  probably  the  same, 
aided  possibly  by  the  local  action  of  toxins  absorbed  from  the  pulmonary  lesion. 
The  application  of  mustard,  blistering  fluids,  or  any  substance  which  induces 
hypersemia  of  the  skin  may  at  times  lead  to  an  increased  growth  of  hair.  Similar 
overgrowths  of  hair  are  occasionally  met  with  in  the  neighborhood  of  chronic 
ulcers,  about  the  ends  of  stumps  which  have  been  for  a  long  time  inflamed, 
and  about  old  diseased  joints.  Sir  James  Paget  records  having  met  with  a 
curious  instance  of  this  kind  in  a  child  about  five  years  of  age.  The  femur 
had  been  fractured  near  the  middle ;  the  case  had  done  badly,  and  union  had 
taken  place  with  much  distortion.  The  affected  thigh  was  covered  with  dark 
hair  like  that  of  a  strong,  coarse-skinned  man,  while  on  the  rest  of  the  body  the 
hair  was  as  delicate  and  soft  as  it  usually  is  in  childhood.  Cases  such  as  these 
cannot  properly  be  regarded  as  the  result  of  inflammation,  for  the  growth  of 
hair  is  usually  at  such  a  distance  from  the  inflamed  area  as  to  preclude  the 


Fig.  56. — Hypertrophied  Toe  Nails,  Removed  by  Operation. 
{Pathological  Museum,  McGill  University.) 


DISTURBANCES  OF  NUTRITION. 


159 


possibility  of  any  morbid  influence,  save  that  of  hypersemia  alone.  This  would 
appear  also  to  be  indicated  by  Hunter's  classical  experiment  of  transplanting 
the  spur  of  a  cock  upon  its  comb.  The  comb  is  highly  vascular,  and  the  trans- 
planted spur  reached  striking  dimensions,  being  about  six  inches  long  and 
spirally  curved.  It  may  possibly  be  that  the  congenital  hypertrophies  known 
as  partial  or  local  gigantism  are  a  consequence  of  increased  vascularity, 
although  this  has  never  been  proved. 

Closely  akin  to  this  last  form  are  the  hypertrophies  due  to  chronic 
irritation.  Here  an  important  factor  is  pressure.  Constant  pressure  usually 
produces  atrophy  or  necrosis.  Intermittent  pressure,  on  the  other  hand, 
often  leads  to  hypertrophy.  Common  instances  of  this  are  corns,  the  cal- 
luses on  the  hands  of 
workingmen,  and  on  the 
feet.  The  necessary  con- 
ditions appear  to  be  a 
period  of  stimulation  and 
a  period  of  rest,  to  allow 
the  processes  of  nutrition 
to  go  on.  The  effect  of 
this  is  a  hyperplasia  and 
hyperkeratinization  of  the 
epidermis,  which  leads  to 
pressure  upon  the  papil- 
lary layer  and  consequent 
irritation.  Subsequently 
adaptation  may  be  so  far 
carried  out  that  a  secret- 
ing bursa  may  be  formed 
beneath  the  corn  for  the 
protection  of  the  joint. 

More  interesting  still 
are  the  cases  of  elonga- 
tion and  enlargement  of 
bones  resulting  from  in- 
flammation. In  inflam- 
mation we  have  not  only 

the  influence  of  an  increased  flow  of  blood  and  increased  nutrition,  but  often 
also  the  stimulating  effect  of  toxins,  bacterial  or  metabolic. 

Normally  the  growth  of  bone  depends  on  the  activity  of  certain  specialized 
cells — the  osteoblasts — which  are  chiefly  situated  in  the  deeper  layers  of  the 
periosteum,  at  the  extremities  of  the  long  bones,  and  at  the  interosseous  sutures. 
Growth  in  thickness  takes  place  by  subperiosteal  osteoplasia ;   growth  in  length 


Fig.  57. — New  Growth  of  Osteophytes  about  the  Hip  Joint,  the 
Result  of  Chronic  Arthritis.  {Pathological  Museum,  McGill  Uni- 
versity.) 


160 


AilERICAN  PRACTICE  OF  SURGERY. 


is  due  to  the  action  of  the  osteoblasts  situated  at  the  spongy  ends  of  bones  and 
in  the  epiphyseal  cartilages.  Increase  in  length  of  a  bone  depends  not  only  on 
the  inherent  vegetative  power  of  the  cells,  but  also  on  the  condition  of  the  epi- 
physeal discs.  Growth  in  length  can  occur  only  so  long  as  the  epiphyses  are  un- 
united to  the  shaft.  After  this  takes  place,  growth  in  thickness  and  Ln  density 
is  alone  possible.  In  young  individuals,  then,  irritation  in  the  neighborhood  of 
the  ends  of  a  bone  may  result  in  increase  in  its  length.  Experimentallj',  in  rab- 
bits, the  length  of  the  bones 
can  be  increased  by  driving 
ivorj'  pegs  into  the  epiphyseal 
discs.  The  effect  of  chemical 
substances  is  well  illustrated 
also  in  the  experiments  of 
Wegner,  who  was  able,  by 
feeding  rabbits  for  a  pro- 
longed period  with  minute 
doses  of  phosphorus,  to  pro- 
duce stimulation  at  the  epi- 
physeal sutures,  with  conse- 
quent increase  in  the  length 
of  the  long  bones.  Arsenic 
has  a  similar  effect. 

Chronic  inflammation  af- 
fecting a  bone  or  some  of  the 
tissues  in  its  neighborhood  in  a 
similar  way  leads  to  increase  of 
growth.  (See  Fig.  57.)  Thus 
cases  are  occasionally  met 
with  where,  o-n-ing  to  necrosis 
of  some  part  of  the  femur,  that 
bone  has  elongated  tmtil  the 
limb  was  an  inch  or  two  longer 
than  its  fellow.  In  such  a  case 
the  femur  does  not  materially  alter  its  shape  or  direction.  It  is  different,  how- 
ever, with  the  tibia.  The  tibia  is  bound  to  the  fibula  at  each  end  by  liga- 
ments, and  when  it  elongates  it  must  necessarily  assume  a  curved  position 
unless  the  fibula  enlarges  simultaneously.  The  stimulating  influence  of  the 
irritation  may,  indeed,  be  traced  to  a  considerable  distance  from  the  site  of  the 
lesion.  Instances  are  on  record  where  necrosis  of  the  tibia  and  shortening  of  the 
leg  have  been  followed  by  a  compensatory  elongation  of  the  femur,  so  that 
the  limb  as  a  whole  was  eventually  no  shorter  than  the  other.  Chronic  ulcers 
of  the  skin  and  subcutaneous  tissues  are  sometimes  followed  by  elongation 


Fig.  58. — Femur;  Ununited  Fracture  through  the  Great 
Trochanter ;  Excessive  Growth  of  New  Bone.  {Pathological 
Museum,  McGill  University.) 


DISTUEBANCES  OF  NUTRITION. 


161 


and  enlargement  of  the  underlj-ing  bone.  Similarly,  hj^pertrophy  may  occur 
to  repair  a  structural  defect.  In  a  badly  imited  fracture  the  permanent  callus 
is  often  rery  large.  (See  Fig.  58.)  It  has  been  shown  also,  in  dogs,  that 
removal  of  a  portion  of  the  radius  is  followed  by  an  increase  in  size  of  that 
portion  of  the  ulna  which  is  directly  opposite  to  the  loss  of  substance. 

Another  aspect  of  the  subject  should  also  be  referred  to.    Where  the  epiphys- 
eal cartilages  are  united  to  the  shaft  of  the  bone,  as  in  adults,  or  have  been  de- 


FiG.  59. — Spondylitis  Deformans;    Car\-ature     :    '  !     ~ 
Osteogenesis.      (Pathological  Museum,  McGill  VnivenrUij.) 


with  Ank^'loais,  due  to  Subperiosteal 


stroyed  by  disease,  increase  in  length  of  the  affected  bone  is  no  longer  possible, 
but  increase  in  its  thickness  may  take  place.  And,  in  fact,  even  in  young  per- 
sons more  or  less  periosteal  osteogenesis  usually  accompanies  any  increase  in 
length.  Increase  in  the  thickness  of  the  bone  is  a  not  infrequent  event  in  such 
affections  as  chronic,  osteitis  periostitis,  and  osteomyelitis.  (See  Fig.  59.)  The 
overgrowth  of  the  bone  is,  moreover,  not  entirely  the  result  of  external  accretion, 
due  to  stimulation  of  the  subperiosteal  osteogenetic  layer,  but  to  an  alteration 


162  .\]*IERIC-\X   PRACTICE  OF  SURGERY. 

of  its  internal  structure.  There  is,  in  addition,  a  deposit  of  new  bone  on  the  tra- 
beculse,  so  that  the  cancellar  spaces  are  obhterated  and  the  textui'e  of  the  bone 
becomes  more  dense  and  approximates  to  ivory  (osteosclerosis).     (See  Fig.  60.) 

As  we  have  hinted  above,  growth  and  development  are  in  large  measure 
a  question  of  metabolism.  In  this  connection  the  internal  secretions  are  of  the 
utmost  moment.    No  doubt  all  the  ductless  glands  pla}^  an  important  role,  but 


Fig.  60. — Sclerosis  of  the  Calvarium,  of  S3T5liilitic  Origin.  Note  the  thickness  of  the  segment  of 
bone  (at  lower  part  of  the  picture),  which  is  also  dense  and  ivory-like.  (Pathological  Museum,  McGill 
University.) 

three  of  them  stand  out  pre-eminently.  These  are  the  thyroid,  the  pituitary, 
and  the  testes.  The  relationships  that  exist  between  these  organs  are  numerous 
and  cannot  be  entered  into  fully  here.  There  can  be  no  question,  however,  that 
a  certain  mutual  balance  of  fimctional  activity  on  the  part  of  these  structures  is 
essential  for  the  maintenance  of  normal  growth  and  de-s-elopment.  Should  this 
balance  be  upset,  metabolism  is  disordered  and  disease  is  the  result.  The  body 
as  a  whole  may  be  involved  or  some  part  of  it.    The  changes  are  manifested 


DISTURBANCES   OF  NUTRITION.  163 

mainly  in  the  direction  of  aplasia,  hypoplasia,  atrophy,  or  hypertrophy.  A  fa- 
miliar instance  of  imperfect  growth  and  development  of  this  type  is  cretinism, 
which  is  now  generally  admitted  to  be  the  result  of  athyroidea.  Of  the  opposite 
condition,  namely,  excess  of  growth,  we  may  cite  the  elongation  of  the  bones 
which  occurs  after  castration.  The  posterior  pair  of  limbs  is  usually  increased 
in  length  in  eunuchs,  oxen,  and  capons.  The  overgrowth  of  hair  that  sometimes 
occurs  on  the  faces  of  women  who  have  passed  the  menopause,  or  who  are  the 
subjects  of  ovarian  disease,  is  possibly  also  of  this  nature. 

The  most  striking  example,  however,  is  acromegaly.  In  this  curious  disease, 
as  Marie  put  it,  there  is  a  massive  hypertrophy  of  bones  of  the  extremities  and 
of  the  extremities  of  the  bones.  The  hands  are  spadelike  and  the  fingers  rounded. 
The  lips,  tongue,  nose,  cheeks,  and  ears  become  thickened,  and  a  characteristic 
prognathic  facies  is  in  time  produced.  In  severe  cases  all  the  bones  of  the  body 
are  affected.  The  thorax  enlarges  and  the  trunk  becomes  scoliotic.  With  this 
there  are  minor  peculiarities,  general  physical  and  mental  asthenia,  trophic  dis- 
turbances of  the  skin,  and  sexual  apathy.  In  the  vast  majority  of  cases  ^some 
lesion  of  the  pituitary  body  has  been  found,  such  as  hypertrophy,  cystic  or  ade- 
nomatous tumors.  Whether,  however,  the  disease  is  the  result  of  an  increased, 
a  diminished,  or  a  perverted  pituitary  secretion  is  a  question  which  at  present 
must  be  tmanswered. 

Lastly,  we  have  to  discuss  certain  hypertrophies,  which,  for  want  of  a  better 
explanation,  may  be  called  neurotrophic.  Such  are,  possibly,  the  cases  known 
as  "idiopathic  hypertrophy  of  the  heart."  Here,  the  heart  is  hypertrophied  in 
the  absence  of  all  of  the  ordinary  conditions  which  produce  this,  such  as  arterio- 
sclerosis, nephritis,  emphysema  of  the  lungs,  and  valvular  lesions  of  the  heart. 
Cases  have  been  attributed  to  mental  overwork,  worry,  and  the  abuse  of  tea  and 
coffee.  It  is  conceivable  that  in  such  cases  there  may  be  some  functional  dis- 
turbance of  the  nerve  terminals  or  ganglia  in  the  heart  muscle.  Of  a  similar 
nature  appear  to  be  those  cases  of  hypertrophied  bladder  which  are  occasionally 
seen  in  children  who  suffer  from  frequent  and  painful  micturition,  with  most  of 
the  symptoms  of  calculus.  No  calculus  is  present,  however,  and  at  autopsy  no 
disease  of  the  urinary  organs  is  found  other  than  hypertrophy.  The  condition 
appears  to  be  due  to  a  too  frequent  and  powerful  action  of  the  vesical  muscle. 
Possibly  it  is  to  be  attributed  to  a  spasmodic  contraction  of  the  muscles  about 
the  urethra,  causing  a  temporary  obstruction.  This  incoordinate  action  of  the 
muscle  is  very  likely  the  result  of  disturbed  innervation. 

ATROPHY. 

The  term  "atrophy,"  from  its  derivation,  implies  wasting,  lack  of  nourish- 
ment. In  pathological  language  it  means  a  condition  or  process  in  which  the 
cardinal  feature  is  diminution  in  size  of  a  tissue  or  organ,  either  from  a  decrease  in 


164  AMERICAN  PRACTICE  OF  SURGERY. 

the  size  of  its  constituent  cells  or  from  a  diminution  in  the  number  of  these  cells, 
or  both.  We  may,  therefore,  distinguish  between  a  quantitative  and  a  numerical 
atrophy.  The  distinction  is,  however,  entirely  theoretical,  for  it  is  practically 
impossible  to  separate  the  two  conditions.  Provided  that  the  cause  remain 
constantly  acting,  a  cell  which  at  first  only  becomes  diminutive  will  in  time 
disappear  altogether.  Atrophy  is  in  most  respects  the  antithesis  of  hypertrophy. 
In  hypertrophy  the  size  and  number  of  the  tissue  elements  increase,  resulting 
in  augmentation  of  function.  The  affected  part  becomes  larger.  In  atrophy 
the  part  wastes  from  diminution  of  its  substance,  and  its  function  is  correspond- 
ingly impaired. 

As  we  have  seen  in  the  preceding  section,  we  have  two  kinds  of  hypertrophy 
— hypertrophy  with  growth  and  hypertrophy  with  development.  Similarly  we 
may  recognize  two  forms  of  atrophy — atrophy  with  simple  wasting  and  atrophy 
with  degeneration.  It  is  not  always  possible  to  make  this  distinction  in  any 
given  case,  for,  as  a  matter  of  fact,  a  wasting  tissue  not  infrequently  degenerates, 
and,  conversely,  a  degenerated  tissue  is  usually  smaller.  Still,  however,  it  con- 
duces to  precision  of  thought  to  preserve  this  distinction  in  our  minds  and  to 
use  the  term  "atrophy"  in  a  more  restricted  sense,  namely,  to  indicate  a  simple 
loss  of  substance,  without  connoting  any  other  retrogressive  change.  It  is 
well,  also,  before  going  further,  to  get  a  clear  idea  of  certain  terms  which  are 
not  infrequently  confused  with  "atrophy."  These  are  agenesia,  aplasia,  and 
hypoplasia.  Agenesia  and  aplasia  mean  complete  failure  of  a  part  to  develop. 
It  is  rare,  however,  for  this  to  be  absolute.  Hypoplasia  is  underdevelopment. 
The  causes  which  induce  these  peculiarities  operate  at  different  periods  of  life. 
Aplasia  and  agenesia  arise  during  early  foetal  existence;  hypoplasia  occurs  some- 
what later,  but  before  complete  development  has  been  attained.  All  blighting 
or  imperfect  development  of  parts  is  to  be  regarded  as  aplasia  or  hypoplasia. 
Atrophy  may  occur  at  any  time  during  the  life  of  the  individual  and  implies 
a  retrograde  decrease  in  size  after  the  affected  part  has  been  developed,  either 
completely  or  as  far  as  it  will  go.  The  same  causes  which  may  induce  atrophy 
in  a  perfected  organ  may,  on  occasion,  produce  it  in  one  imperfectly  developed, 
so  that  we  must  broaden  our  definition  of  atrophy  to  include  all  cases  of  dimin- 
ution in  size  of  the  cells  of  a  part,  whether  these  cells  be  perfect  or  imperfect. 
Degenerative  atrophy  differs  from  simple  atrophy  in  that  the  retrogressive 
changes  which  are  present  begin  in  the  cytoplasm  and  nuclei,  and  later  give 
rise  to  the  decrease  in  size. 

We  can  understand  the  philosophy  of  atrophy  only  if  we  constantly  bear  in 
mind  the  principles  already  enunciated.  As  we  have  seen,  all  cells  possess  an 
inherent  vital  energy,  which  is  manifested  in  the  functions  of  assimilation,  nutri- 
tion, and  reproduction.  Continuance  in  life,  to  say  nothing  of  growth  and 
development,  depends  solely  upon  the  maintenance  of  a  certain  balance  between 
the  nutritive  or  building-up  forces  and  the  destructive  or  wasting  processes. 


DISTURBANCES  OF  NUTRITION.  165 

During  early  life,  when  anabolism  is  in  excess,  growth  and  development  and  the 
manifestations  of  a  vigorous  energy  are  dominant  features.  Later,  there  comes 
a  period  of  equilibrium,  during  which  the  bodily  powers  are  at  their  highest 
consummation.  Later  still,  when  the  natural  decay  sets  in,  the  faculties  begin 
to  fail  and  the  machinery  to  give  out,  until  the  various  functions  can  no  longer 
be  performed  and  the  individual  dies.  Nutrition  and  waste  are  the  two  oppos- 
ing powers.  Atrophy  of  tissue  may,  on  the  one  hand,  result  from  imperfect 
nutrition  and  diminished  repair,  and,  on  the  other,  from  excessive  consumption 
and  waste.  In  the  first  instance  nutrition  of  tissue  is  largely  dependent,  apart 
from  the  inherent  vegetative  force  before  referred  to,  on  a  sufficient  supply  of 
healthy  blood  and  lymph,  and  on  the  existence  of  proper  nervous  stimuli.  Airy 
disease  process  which  interferes  with  the  amount  of  blood  reaching  a  part,  or 
deteriorates  its  quality,  or,  again,  cuts  off  the  cells  from  their  neurotrophic 
centres,  results  in  atrophy.  On  the  other  hand,  anything  which  increases  tissue 
waste,  as,  for  instance,  overactivity,  will  give  rise  to  atrophy. 

It  should  be  remarked  here  that  there  is  a  general  law  in  pathology  which 
governs  the  extent  and  the  localization  of  retrogressive  processes,  atrophies 
included.  The  more  delicate  and  highly  specialized  a  cell  or  tissue  is,  the  more 
susceptible  it  is  to  external  impressions;  and,  when  injured,  the  less  its  power  of 
repair.  Therefore,  the  parenchyma  of  an  organ,  the  secreting  structure  of  a 
gland,  suffers  more  from  deteriorating  influences  than  does  the  stroma.  The  epi- 
thelium of  the  kidney  and  the  parenchymatous  cells  of  the  liver  may  waste  with- 
out material  diminution  in  the  connective-tissue  framework.  As  a  consequence, 
such  an  organ,  when  the  subject  of  atrophy,  often  becomes  harder  and  more 
fibrous  than  normal,  or  the  destroyed  cells  are  replaced  by  newly  formed  connec- 
tive tissue.  This  change  is  commonly  called  induration.  In  such  a  case  the  or- 
gan affected  becomes  not  only  smaller,  but  its  surface  is  often  irregular,  nodular, 
or  warty.  A  change  in  external  size  and  configuration  is,  however,  not  necessary 
in  all  cases.  For  example,  in  bone,  atrophy  may  affect  the  trabeculae  of  the 
spongy  portion  and  the  parts  bordering  on  the  medullary  cavity.  The  bone  in 
this  way  becomes  lighter  and  more  porous,  but  may  not  be  smaller  (osteoporosis). 

Microscopically,  the  cells  of  the  affected  organ  are  smaller  and  usually  fewer 
than  normal.  In  the  early  stages  of  the  process  they  usually  stain  well  and  the 
finer  structure  is  well  preserved.  In  more  advanced  cases  the  cells  may  be  con- 
siderably shrunken  and  deformed,  and  there  may  be  either  an  absolute  or  a  rela- 
tive increase  in  the  pigment  (atrophia  pigmentosa).  Pigmentary  changes  are 
often  well  seen  in  the  case  of  the  heart  muscle  and  the  secreting  cells  of  the  liver. 
Atrophied  ganglion  cells  are  generally  highly  pigmented.  In  the  most  advanced 
stages  the  cytoplasm  has  all  but  disappeared  and  little  remains  but  a  shrunken, 
distorted  nucleus,  which  in  its  turn  fragments  and  disappears.  In  certain  cases, 
as  in  muscle,  the  loss  of  substance  is  made  good,  so  far  at  least  as  bulk  is  con- 
cerned, by  an  overgrowth  of  the  connective  tissue  in  which  fat  is  eventually 


166  AMERICAN  PRACTICE  OF  SURGERY. 

deposited  {atrophia  lipomatosa).  This  appears  to  be  an  attempt  at  compen- 
sation. 

It  may  be  inferred  from  what  has  already  been  said  that  we  have  to  recog- 
nize two  broad  classes  of  atrophies— those  which  are  physiological  and  inevi- 
table, and  those  which  are  pathological  and  accidental. 

Physiological  or  histogenetic  atrophy  results  from  the  diminution  of  the  in- 
herent vital  powers  of  the  cells.  It  implies  diminished  repair  rather  than  exces- 
sive waste.  The  potential  energy  of  each  cell  and  tissue  is  directly  proportional 
to  the  amount  of  work  it  has  to  do.  As  the  functional  importance  of  an  organ 
diminishes,  so  does  that  organ  begin  to  atrophy.  When  any  organ  becomes 
useless  in  the  economy  it  quickly  disappears.  Each  organ  and  tissue  has  its 
own  life  period,  and  at  the  termination  of  its  career  inevitably  dies,  even  should 
it  have  at  no  time  been  attacked  by  disease.  The  phenomena  of  atrophy  are  to 
be  observed  in  the  individual  from  the  earliest  embryonic  life  period.  Numerous 
examples  of  this  truth  can  be  cited.  In  the  formation  of  the  placenta  certain 
parts  of  the  membranes  disappear  at  an  early  stage  of  development,  and  with 
the  formation  of  the  chorion  there  is  coincidently  a  progressive  atrophy  of  the 
villi.  The  full-term  placenta  has  fulfilled  its  purpose  and  is  therefore  cast  off. 
In  the  case  of  the  foetus  itself,  the  Wolffian  and  Muellerian  ducts,  the  Wolffian 
bodies,  the  umbilical  vesicle,  and  the  omphalomesenteric  duct  disappear  quite 
early.  Before  birth  certain  blood-vessels  begin  to  be  obliterated,  and  a  few  days 
after  birth  the  closure  of  the  Ductus  Botalli  and  the  umbilical  vessels  has 
already  taken  place.  The  spontaneous  separation  of  the  umbilical  cord  is 
also  a  manifestation  of  atrophy.  Later  the  milk  teeth  are  cast  off.  After 
puberty  the  thymus  gland,  which  at  first  is  one  of  the  most  prominent  struc- 
tures in  the  body,  rapidly  wastes  away.  With  the  approach  of  middle  life, 
lymphoid  structures  begin  to  waste  and  portions  of  the  petrous  and  sphenoid 
bones  disappear.  Hyaline  cartilage  in  some  persons  is  in  time  converted  into 
bone.  With  the  onset  of  old  age  the  uterus  and  ovaries  begin  to  shrink,  and 
with  the  induction  of  the  menopause  their  function  ceases.  This  atrophy  of  the 
ovaries  is  due  to  sclerotic  changes  in  the  ovarian  arteries,  in  which  involution 
changes  seem  to  begin  sooner  than  in  the  vessels  elsewhere  in  the  body.  In  ad- 
vanced life  the  lymphadenoid  structures,  the  muscles,  bones,  and  in  many  cases 
the  subcutaneous  fat,  begin  to  retrograde.  The  lungs,  kidneys,  and  liver  are  often 
considerably  involved  in  the  process,  the  brain  and  nervous  system  to  a  compar- 
atively slight  extent,  as  a  rule.  The  posture,  gait,  the  blanched  hair,  and  gen- 
eral appearance  of  the  aged  are  due  to  these  atrophic  changes.  The  cardio- 
vascular system,  on  the  contrary,  may  suffer  slightly,  if  at  all.  The  heart  often 
increases  in  size  and  strength  into  advanced  life,  the  blood  corpuscles  are  formed 
as  before,  and  defects  of  vessels,  connective  tissue,  and  epithelium  are  usually 
quickly  made  good.  The  arteries  themselves,  however,  may  tmdergo  sclerotic 
changes.    This  is  an  important  factor  in  the  causation  of  the  senile  atrophy,  in- 


DISTURBANCES  OF  NUTRITION.  167 

asmuch  as  the  nutrition  of  the  tissues  is  interfered  with  and  in  this  way  the  nor- 
mal retrograde  processes  are  accelerated.  In  the  category  of  physiological  atro- 
phy must  also  be  included  the  normal  involution  of  the  uterus  which  ordinarily 
occurs  after  parturition.  Some  of  these  physiological  atrophies  are  of  considerable 
practical  importance.  The  brittleness  of  the  bones  in  old  age  is  an  important  pre- 
disposing cause  of  fractures.  Fractm'e  of  the  neck  of  the  femur  is  not  uncommon 
and  may  result  from  but  slight  violence.  Not  only  the  osseous  fragility  is  here  to 
be  taken  into  account,  but  also  the  alteration  of  the  angle  which  the  neck  of  the 
femur  makes  with  the  shaft,  as  it  weakens  the  resisting  power  of  the  part. 

Pathological  atrophj^  may  result  (1)  from  inactivity  or  disuse,  (2)  from  over- 
•  activity,  (3)  from  impaired  nutrition,  (4)  from  pressure,  (5)  from  neurotrophic 
disturbance. 

Atrophy  from  Inactivity  or  Disuse.— The  proper  tone  of  a  muscle  and  its 
functional  perfection  depend,  on  the  one  hand,  on  the  amount  and  the  kind  of 
nutrition  which  it  receives,  and,  on  the  other,  on  the  regular  and  sufficient  exer- 
cise to  which  it  is  subjected.  A  fully  exercised  muscle  always  has  a  good  blood 
supply.  A  functionless  muscle  receives  less  nourishment  than  a  normally  acting 
one.    The  same  principle  may  be  applied  to  glands  and  other  structures. 

The  loss  of  necessity  for  a  function,  or  the  inability  to  perform  a  function, 
whether  from  some  incapacity  of  the  organ  itself  or  from  any  extraneous  condi- 
tion which  interferes  with  the  performance  of  its  duty,  may  result  in  atrophy. 
The  importance  of  the  lack  of  proper  function  is  seen  in  the  case  of  certain  deep- 
sea  fishes,  which  possess  only  rudimentary  eyes,  in  some  cases  covered  with  skin. 
The  rudimentary,  or,  more  correctly  speaking,  the  remnant  of  the  hind  legs 
found  in  certain  whales  and  reptiles  is  also  a  case  in  point.  Again,  in  cases  of 
marasmus  or  malassimilation  the  heart  may  be  found  to  be  quite  small,  below 
the  average  weight.  This,  in  part  at  least,  no  doubt  may  be  traced  to  the  less- 
ened demand  upon  its  services.  There  is  less  blood,  and  therefore  less  force  is 
needed  to  propel  it.  There  is  less  demand  also  for  oxygenation.  In  such  cases 
the  atrophy  is  to  be  attributed  as  well  to  lack  of  noiu^ishment  of  the  heart  muscle 
itself.  The  atrophy  of  the  acetabulum  which  occurs  in  cases  of  unreduced  dis- 
location of  the  femur,  the  removal  of  the  callus  when  a  fractured  bone  has  re- 
united, and  the  atrophy  of  the  nerves  after  the  amputation  of  a  limb  also  come 
under  this  category.  An  organ  or  structure  may  be  miable  to  perform  its  usual 
function,  owing  to  some  disturbance  of  its  innervation  or  from  some  mechanical 
hinderance.  Thus  in  paralytic  cases  the  muscles  and  bones  will  in  time  waste. 
A  similar  result  follows  the  immobilization  of  a  limb,  a  deformity,  fixation  of  a 
joint,  or  the  presence  of  a  tumor  which  interferes  with  the  function  of  the  part. 

Atrophy  from  Overactivity. — It  has  been  shown  above  that  an  increased 
demand  upon  the  functional  activity  of  a  part  results  in  hypertrophy.  This 
process,  however,  has  its  limits.  The  moment  the  reserve  power  of  the  structure 
is  encroached  upon,  we  see  the  beginning  of  the  end.    The  part  gradually  fails 


168  MIERICAN  PRACTICE  OF  SURGERY. 

to  respond,  and  hypertrophy  gives  place  to  atrophy.  Overase  of  an  organ  acts 
by  increasing  waste  and  by  giving  the  structure  no  time  to  recuperate.  There- 
fore, ehmination  is  diminished  and  the  toxic  products  of  metabohsm  accmnulate 
in  the  tissues.  Fatigue  is  the  keynote  of  the  process.  The  failure  of  compensa- 
tion in  a  heart  which  previously  may  have  been  hypertrophied  is  a  case  in 
point.  The  brain  is  the  chief  organ  which  may  be  thus  affected.  Of  glandular 
organs,  probably  the  testicles  most  often  suffer. 

Atrophy  from  Impaired  Nutrition. — This  is  the  atrophy  which  is  foimd 
typically  in  cases  of  starvation  and  in  all  forms  of  chronic  wasting  disease.  It  is 
sometimes  called  marantic  atrophy.  The  condition  depends  in  the  main  on  the 
fact  that  the  cells  are  receiving  an  insufficient  amount  of  nutrition  for  their 
needs.  The  extent  and  the  rapidity  of  the  atrophy  depend  upon  the  degree  of 
metabolic  change  which,  the  affected  part  is  able  to  tmdergo.  Adipose  tissue, 
for  example,  quickly  disappears  if  there  be  any  lack  in  the  fat  or  fat-forming 
substances  which  are  supplied  to  it.  The  bones  become  soft  and  wasted  if  the 
lime  salts  are  witlilield.  It  is  likely  also  that  the  deficient  amount  of  haemo- 
globin in  the  red  corpuscles  is  due  to  the  deficient  absorption  of  iron.  Marantic 
atrophy  may  be  general  or  local.  General  atrophy  of  the  body  is  found  in  cases 
of  starvation,  whether  from  insufficient  suppl}^  of  food  or  from  any  condition  of 
the  digestive  apparatus  which  prevents  its  proper  absorption  and  assimilation. 
In  such  cases  the  fat,  muscles,  blood,  and  abdominal  organs  are  chiefly  affected. 
The  fat  disappears  first,  so  that  the  angles  of  the  body  are  exaggerated,  the  eyes 
sink  in,  and  the  whole  body  assumes  a  gaunt  appearance.  The  muscles  may  be 
reduced  to  half  their  original  size.  The  liver,  spleen,  and  intestines,  of  the  ab- 
dominal viscera,  suffer  most.  The  central  nervous  system,  the  bones,  and  the 
heart,  on  the  other  hand,  show  but  little  change.  Curiously  enough,  lipomata 
do  not  decrease  in  size,  even  in  cases  where  the  ordinary  fat  of  the  body  has  dis- 
appeared. 

Local  atrophies  are  usually  due  to  local  causes.  Thus  disease  or  injury  of 
blood-vessels  may  cause  atroph}^  of  the  part  supplied  by  cutting  off  the  nom'ish- 
ment.  Sclerosis  or  other  conditions  leading  to  obstruction  or  obliteration  of 
vessels  will  produce  atrophy  of  the  part  involved,  usually  with  other  degenera- 
tive changes.  We  find  this,  for  example,  in  the  heart,  from  obstruction  of  the 
coronaries;  in  the  kidney,  from  obliteration  of  a  branch  of  the  renal  artery;  and 
in  the  brain,  from  a  similar  condition.  Circulating  toxins,  by  their  deteriorating 
action  on  the  blood  and  possibly  by  a  direct  local  effect,  may  bring  about  atrophy. 
The  long-continued  use  of  iodine  is  sometimes  followed  by  wasting  of  the  thy- 
roid and  mammae.  In  certain  cases  of  fracture  of  the  femur  or  of  other  bones, 
the  circulation  through  the  great  nutrient  artery  may  be  cut  off,  and  atrophy  of 
the  portion  of  the  bone  thus  deprived  of  its  food  supply  follows.  Necrosis  does 
not  occur,  because  there  are  sufficient  anastomoses  remaining  to  preserve  vi- 
tality. 


DISTURB.\XCES  OF  NUTRITION. 


169 


Atrophy  from  Pressure.— It  was  pointed  out  above  that  pressure,  if  inter- 
mittent, especially  if  combined  with  friction,  leads  to  hypertrophy.  Contmu- 
ous  pressure,  on  the  other  hand,  will  produce  atrophy.  This  is  in  part  the  result 
of  direct  mjury  to  the  cells  at  the  site  of  the  lesion,  but  it  is  also  due  to  the  circula- 
tory disturbances  mduced.  This  form  of  atrophy,  therefore,  is  passive  in  its  nature. 
It  is  usually  the  result  of  slight  pressure  exerted  over  a  prolonged  period  of  time. 
Numerous  examples  might  be  cited.  Among  the  best  known  are  the  "lacing" 
or  "corset"  liver  and  spleen,  the  foot  of  the  Chinese  lady,  the  flat  head  and  flat 


Fig.  61. — Atrophy  of  the  Bodies  of  the  Vertebrae  from  the  Pressure  of  an  Aneurism. 
3fuseum,  McGill  University.') 


{Pathological 


nose  of  certain  tribes  of  Indians.  The  pressure  of  tumors,  aneurisms,  cysts,  vari- 
cose veins,  may  lead  to  atrophy  of  the  adjacent  structures  (see  Fig.  61).  Malposi- 
tion of  bones,  as  in  scoliosis,  genu  valgum,  pes  valgus,  by  altering  the  direction 
of  the  pressLU-e,  will  lead  to  atrophy  of  the  parts  unduly  pressed  upon.  The  cal- 
varium  may  be  thinned  from  the  pressure  of  a  hydrocephalic  brain,  from  tu- 
mors, and  from  enlarged  Pacchionian  bodies,  or,  extemalh',  from  wens.  Disap- 
pearance of  the  alveolar  processes  of  the  jaws  sometimes  results  from  the 
loss  of  teeth,  the  bone  being  in  this  case  subjected  to  unusual  pressiu-e.  In  con- 
genital dislocation  of  the  hip-joint,  reposition  of  the  head  of  the  femiu,  with 


170  AMERICAN  PRACTICE  OF  SURGERY. 

maintenance  in  the  new  position,  will  lead  to  the  excavation  of  a  new  ace- 
tabular cavity. 

Perhaps  less  conspicuous,  but  equally  complete  in  their  way,  are  the  local 
atrophies  which  result  from  the  pressm-e  of  inflammatory  exudates,  scars,  and 
constricting  fibrous  bands.  In  the  so-called  "nutmeg"  liver  the  columns  of  par- 
enchymatous cells  about  the  centrilobular  vein  present  extensive  atrophy,  usu- 
ally combined  with  fatty  degeneration,  the  result  of  pressure  from  the  overdis- 
tended  capillaries.    Nutritional  defects  also,  no  doubt,  play  a  part. 

Neurotrophic  Atrophy. — It  is  generally  held  that  there  are  certain  nerve 
cells  or  ganglia  which,  to  some  extent  at  least,  preside  over  the  nutrition  of  the 
tissues  and  structures  innervated  from  them.  These  trophic  centres  are  for  the 
most  part  situated  in  the  anterior  horns  of  the  spinal  cord.  Any  lesion  which 
destroys  these  cells  or  interferes  with  the  conductivity  of  the  fibres  in  the  lower 
motor  neurones  is  followed  by  wasting  of  the  parts  with  which  they  are  con- 
nected. Anterior  poliomyelitis,  progressive  muscular  atrophy,  bulbar  paralysis, 
are  examples  of  this.  In  syringomyelia  and  tabes  dorsalis  atrophy  of  the  bones 
and  joints  may  occur.  The  so-called  Charcot's  joints  are  essentially  atrophic  in 
their  nature.  Disorders  of  the  peripheral  nerves  may  be  followed  by  such  mani- 
festations as  glossiness  and  atrophy  of  the  skin,  exfoliation,  loss  of  hair,  and  dis- 
appearance of  the  cutaneous  glands.  The  diminution  in  size  of  one-half  of  the 
body  which  results  from  luiilateral  disease  of  the  brain  in  fcetal  life  and  early 
childhood,  while  usually  designated  hemiatrophy,  is  probably  more  correctly  to 
be  regarded  as  a  unilateral  hypoplasia.  Many  of  these  forms  of  atrophy  result- 
ing from  organic  nervous  disease  are  of  practical  importance  to  the  surgeon,  in- 
asmuch as  serious  deformities  of  the  members  may  result.  This  comes  about 
from  the  overaction  of  certain  muscles  which  are  unopposed  by  the  wasted  mus- 
cles. Troublesome  contractures  not  infrequently  occur.  Bedsores,  especially 
those  which  develop  rapidly  in  cases  of  organic  nervous  disease,  are  in  large  part 
trophic  in  character. 

It  should  be  remarked  that,  in  the  class  of  cases  just  referred  to,  neurotrophic 
disturbance  is  not  the  only  factor  to  be  taken  into  account.  The  loss  of  nervous 
impulses  leads  to  paralysis  of  the  muscles,  and  this  brings  on  the  atrophy  of 
disuse.  Again,  certain  vasomotor  changes  are  induced,  which  interfere  with  the 
nutrition  of  the  part.  As  a  result  of  these  alterations  inflammatory  processes 
are  readily  set  up,  induced  by  causes  which  would  otherwise  be  ineffectual. 
Probably  the  neurotrophic  atrophies  are  examples  of  degenerative  rather  than 
of  simple  atrophy. 

Atrophy  as  It  Affects  Certain  Tissues  and  Organs. — Muscle. — Voluntary 
muscles  when  atrophic  may  be  much  reduced  in  size,  owing  to  thinning  and  dis- 
appearance of  the  individual  elements.  The  muscles  are  also  paler  and  softer 
than  normal,  dry  and  ana3mic.  They  are  frequently  tough,  owing  to  a  relative 
or,  in  some  cases,  an  absolute  increase  in  the  interstitial  connective  tissue.    In 


DISTURBANCES  OF  NUTRITION.  171 

such  cases  the  muscle  as  a  whole  is  somewhat  grayish  in  color.  The  amount 
of  wasting  may  be  so  extreme  as  to  give  the  impression  of  there  being  nothing 
between  the  skin  and  the  bone  (living  skeleton).  In  other  cases,  owing  to  an 
increased  deposit  of  fat  between  the  fibres,  the  muscle  appears  to  be  of  normal 
size  (atrophia  musculonim  li-pomatosa) ,  or  it  may  be  even  larger  than  normal 
(pseudo-hypertrophic  muscular  paralysis).  The  natural  pigment  of  the  muscle 
fibre  may  be  relatively  or  absolutely  increased,  causing  the  muscle  to  assume 
a  brownish  appearance.  This  is  often  well  seen  in  the  heart  (hrown  atrophy). 
Microscopically,  the  individual  fibres  appear  to  be  shrunken,  and  are  often  tor- 
tuous. The  striae  are  usually  well  preserved.  The  nuclei  of  the  endomysium 
proliferate  more  or  less.  When  the  atrophy  is  complete  the  sarcolemma  sheaths 
are  found  to  contain  pigment,  nuclei,  and  multinucleated  cells. 

There  are  one  or  two  important  forms  of  muscular  atrophy  which  deserve 
more  than  a  passing  mention. 

Atrophy  from  disuse  may  be  brought  about  by  fracture  of  a  muscle,  tendon, 
or  bone,  ankylosis  of  joints,  fixation  by  splints,  or  even  by  voluntary  inactivity. 

In  the  neuropathic  atrophies  the  process  is  largely  confined  to  certain  mus- 
cles or  groups  of  muscles.  These  atrophies  may  be  spinal,  bulbar,  or  cerebral 
in  origin,  and  often  attack  the  muscles  that  are  most  used  or  those  which  derive 
their  innervation  from  some  diseased  portion  of  the  central  nervous  system.  In 
manual  laborers  the  muscles  of  the  thenar  and  hypothenar  eminences,  the  inter- 
ossei,  and  the  lumbricales  are  apt  to  be  first  involved  (Aran-Duchenne  type). 
In  other  cases  the  disease  begins  in  the  muscles  of  the  shoulder  and  arm. 

In  cases  of  involvement  of  the  medulla  there  is  difficulty  in  articulation  and 
deglutition,  with  drooling  of  the  saliva  and  feebleness  of  the  voice  (progressive 
bulbar  paralysis). 

Somewhat  closely  resembling  the  spinal  atrophies  is  the  so-called  primary 
myopathy  or  progressive  muscular  dystrophy.  There  are  three  types — the  infan- 
tile, the  juvenile,  and  the  adult.  The  first  usually  begins  in  the  muscles  of  the 
face,  giving  rise  to  a  peculiar,  expressionless  appearance,  the  so-called  myopathic 
facies.  The  juvenile  form  involves  the  muscles  of  the  calves,  thighs,  back, 
shoulder  girdle,  and  arms.  The  adult  type  begins  either  in  the  lower  extrem- 
ities or  in  the  upper  extremities  and  face.  The  anatomical  cause  is  still  a  matter 
of  dispute.  The  pseudo-hypertrophic  form  of  primary  myopathy  occurs  in  chil- 
dren, and  affects  the  muscles  of  the  calves  or  shoulders,  giving  the  child  the 
appearance  of  a  young  prize-fighter.  The  myopathies  are  distinctly  of  a  family 
type.  They  have  a  practical  bearing  for  the  surgeon,  in  that,  when  affecting 
the  lower  extremities,  they  may  produce  club-foot. 

Secondary  atrophies  of  muscles  may  occur  when  nerves  are  cut  in  the  course 
of  operations. 

The  heart,  when  atrophied,  is  reduced  in  size,  the  color  is  darker  than  normal, 
and  the  coronary  vessels  are  tortuous.     The  epicardial  fat  is  likewise  wasted  and 


172 


AMERICAN  PRACTICE  OF  SURGERY. 


in  a  serous  condition.  Atrophj-  of  certain  portions  of  the  heart  may  result  from 
coronarj^  disease  or  fatty  infiltration.  Atrophy  of  certara  fibres  is  often  com- 
bined with  hj'pertrophj'  of  others. 

Lungs. — In  the  so-called  hji^ertrophic  emphysema  there  are  atrophy  and  sec- 
ondary rupture  of  the  alveolar  walls,  so  that  the  spaces  become  enlarged.    Such 


Fig.  62. — Caries  of  the  Upper  End  of  the  Femur :  Abscess 
Museum,  McGUl  University.') 


the  Great  Trochanter.      (Pathological 


limgs  are  more  bulk}'  than  normal,  pale,  and  anfemic.  In  another  form,  atrophic 
emphysema,  the  same  condition  is  combiaed  with  a  diminution  in  bulk  of  the 
whole  lung. 

Bo7WS. — Atrophy  of  bone  may  restilt  from  any  of  the  causes  hitherto  set  forth. 
Old  age,  pressure,  interference  with  function,  impoverished  nutrition,  mflamma- 
tion,  and  nervous  disturbances  maj-  all  play  a  role. 

The  structure  of  the  bony  framework  of  the  body  is  in  health  undergoing 
constant  change.  In  the  child  vegetative  forces  are  in  the  ascendant,  with  the 
result  that  anj^  loss  of  substance  of  the  bone  is  made  good  and  more  than  made 
good,  so  that  the  bones  mcrease  in  size  and  strength.    In  the  adult,  breaking 


DISTURBANCES  OF  NUTRITION. 


173 


down  or  resorption  is  still  going  on,  but  is  compensated  by  a  continuous  deposit 
of  new  bone  through  the  process  of  apposition.  In  the  aged,  resorption  is  in  ex- 
cess, and  therefore  the  bones  become  lighter,  smaller,  and  more  fragile.  Lacunar 
resorption  is  the  process  by  which  atrophy  takes  place.  Certain  large,  multinu- 
cleated cells — osteoclasts — are  present  in  great  numbers  in  the  periosteimr  and 
bone  marrow.  These  take  up 
their  position  on  the  bone  tra- 
beculse  and  gradually  erode  the 
bone,  forming  the  so-called  How- 
ship's  lacima;.  In  the  rapid  re- 
sorption of  bone  characteristic 
of  certain  diseases  the  osteoclasts 
are  greatly  increased  in  numbers 
and  lie  closely  packed  together. 
The  result  is  that  the  surface  of 
the  bone  becomes  eroded  and 
irregular  (concentric  atrophy) 
(see  Fig.  62).  Should  the  proc- 
ess go  on  mainly  about  the 
medullary  cavity,  the  external 
configuration  of  the  bone  is  not 
altered,  but  the  marrow  space 
is  enlarged  and  the  bone  becomes 
thinner  (excentric  atrophy).  In 
still  other  cases  the  compact 
portion  of  the  bone  becomes 
porous,  owing  to  the  widening 
of  the  Haversian  canals  (osteo- 
porosis) (see  Fig.  63). 

Atrophied  bones  are  light, 
fragile,  easily  broken  or  sawn. 
The  medullary  substance  is  of- 
ten lymphoid  in  character,  fatty, 
or  the  fat  may  be  replaced  by  a 
gelatinous-looking  material  (ser- 
ous atrophy). 

Senile  and  marantic  atrophy 
may  affect  the  skeleton  as  a  whole,  but  the  senile  form  is  apt  to  attack  more 
extensively  the  flat  bones,  the  calvarium,  maxillee,  scapula?,  and  pelvis.  The 
process  begins  and  is  most  marked  at  the  points  devoid  of  muscular  attachment. 
Owing  to  the  diminution  in  size  of  the  vertebrae  and  the  intervertebral  discs,  the 
height  of  the  body  is  diminished  and  the  back  becomes  curved.    The  character- 


FiG.  63. — ^Femur  Cut  Longitudinally,  to  show  Rare- 
faction, Osteosclerosis,  and  New  Growth  of  Bone  from  the 
Periosteum.  Case  of  Osteomyelitis.  (Pathological  Mu- 
seum, McGUl  University.) 


174 


AMERICAN  PRACTICE  OF  SURGERY. 


istic  senile  facies  is  due  to  the  absorption  of  the  alveolar  processes.    Atrophy 
from  disuse  is  more  usually  found  in  the  limbs. 

The  atrophy  that  affects  the  bones  after  amputation  is  from  without  and 
leads  to  the  end  of  the  bone  becoming  thinner  and  more  pointed. 

Striking  instances  of  atrophy  from  pressure  are  met  with  in  cases  of  carci- 
noma and  sarcoma  developing  within  a  bone.  Not  only  is  the  bone  rarefied 
but  the  structure  is  expanded.    This  is  the  cause  of  the  so-called  "egg-shell 

crackle,"  which  is  one  of  the 
clinical  features  looked  for  (see 
Fig.  64). 

From  the  point  of  view  of 
structure  the  bones  may  be  re- 
garded as  consisting  of  a  living 
matrix,  in  which  is  deposited  an 
inert,  dead  material,  the  lime 
salts,  which  to  a  large  extent  give 
compactness,  density,  and 
strength  to  the  tissue.  The  rela- 
tive proportions  between  these 
two  elements  may  be  considerably 
altered,  a  state  of  things  which 
may  possibly  with  some  reason  be 
considered  as  a  form  of  atrophy. 
The  proportion  of  calcareous  salts 
is  increased  in  old  age,  an  expres- 
sion of  what  one  might  appropri- 
ately call  the  "  calcareous  diathe- 
sis," which  is  so  characteristic  of 
old  age,  being  found  not  only  in 
the  bones,  but  in  the  cartilages 
and  blood-vessels.  This  does  not 
result  in  an  increase  of  strength 
of  the  bones,  but,  on  the  contrary, 
they  become  more  fragile  than 
normal,  owing  to  excessive  re- 
sorption. 

An  opposite  condition  to  this 
is  halisteresis  or  mollities  ossium,  in  which  the  organic  constituents  of  the  bone 
remain  unaltered,  but  there  is  a  notable  diminution  in  the  amount  of  lime  salts, 
so  that  the  bone  becomes  soft  and  yielding. 

The  most  extreme  form  of  this  is  known  as  osteomalacia.  The  pathological 
changes  at  work  here  consist,  in  the  main,  of  decalcification  of  the  old  bone,  with 


Fig.  64. — Humerus :  Carcinoma  of  Upper  Portion, 
showing  Rarefaction  of  the  Bone.  (Pathological  Museum, 
McGill  University.') 


DISTURBANCES  OF  NUTRITION.  175 

at  the  same  time  a  tendency  to  the  formation  of  new  bone,  which,  however,  re- 
mains imperfectly  calcified.  The  process  of  decalcification  begins  at  the  periph- 
ery of  the  bone  trabeculse  and  gradually  extends  to  the  deeper  parts.  The  line 
of  demarcation  between  the  normal  and  the  diseased  bone  is  sometimes  even  and 
continuous,  but  may  be  irregular  and  with  excavations  like  Howship's  lacunae. 
Often  there  is  formed  an  intermediate  zone,  in  which  the  lime  salts  are  not  com- 
pletely removed,  but  remain  in  the  form  of  a  crumbling  detritus.  Eventually 
the  bone  canals  become  enlarged,  and,  with  the  absorption  of  the  calcareous 
salts,  new  canals  are  formed  in  the  ground  substance.  The  matrix  itself  may  be 
homogeneous  or  may  present  a  finer  or  coarser  fibrillation.  Some  of  the  bone 
corpuscles  may  be  preserved,  but  many  have  atrophied  or  disappeared,  leaving 
small  cavities.  In  some  cases  there  is  a  new  formation  of  osteoid  tissue,  but  it 
remains  for  a  long  time,  or  even  permanently,  uncalcified.  This  new  tissue  may 
be  quite  dense,  containing  only  a  few  spaces,  or  it  may  present  a  laminated  or 
fibrillated  structure  with  large  corpuscles.  Osteoclasts  and  Howship's  lacunte 
are  not  more  numerous  than  in  normal  bone.  The  condition  of  the  marrow 
varies.  It  may  be  reddish  in  color,  with  giant  cells,  yellowish  and  fatty,  gelati- 
nous, or  even  fibroid.    Hemorrhages  and  pigment  are  commonly  to  be  found. 

Osteomalacia  is  a  disease  of  obscure  etiology.  It  appears  to  be  rare  on  the 
North  American  continent.  Dock  finding  records  of  only  ten  cases.  Since  some 
cases  in  women  have  been  cured  by  removal  of  the  ovaries,  Fehling  has  promul- 
gated the  view  that  it  is  a  trophoneurosis  due  to  reflex  irritation  from  the 
ovaries. 

A  condition  of  some  practical  interest  to  the  surgeon  is  osteopsathyrosis,  or 
abnormal  brittleness  of  the  bones.  This  term  is  used  in  a  general  way  as  synony- 
mous with  fragilitas  ossium.  The  bones  become  fragile,  and  are  therefore  easily 
broken.  A  slight  movement,  a  jar,  or  even  muscular  action  may  be  sufficient 
to  bring  about  this  result.  The  condition  is  a  retrograde  metamorphosis, 
and  is  met  with  especially  in  senile  and  cachectic  conditions.  Rarely,  the 
condition  is  congenital  and  may  be  inherited.  In  this  case  it  appears  to  be  a  de- 
velopmental anomaly,  for  it  has  been  found  combined  with  dwarfism  or  associ- 
ated with  dwarfism  in  related  individuals. 

Osteopsathyrosis  occurs  as  a  result  of  old  age,  cachexia,  prolonged  activity, 
pressure  atrophy,  and  neurotrophic  atrophy.  It  is  met  with  in  locomotor  ataxia, 
syringomyelia,  general  paresis  of  the  insane,  and  osteomalacia.  It  is  also  found 
in  certain  inflammatory  conditions,  such  as  rickets,  syphilis,  and  leprosy.  In 
inveterate  syphilis  with  cachexia  there  is  often  a  marked  fragility  of  the  long 
bones  especially,  and  also  of  the  cranium.  A  somewhat  similar  condition  of  os- 
teoporosis is  the  result  of  actinomycosis  and  Madura  foot  disease. 

The  Nervous  System. — The  subject  of  atrophy  of  the  nervous  system  is  one 
that  is  beset  with  great  difficulties  and  uncertainties.  Here,  as  in  so  many  cases, 
we  cannot  draw  any  distinction  between  atrophy  and  degeneration.    We  may 


176  A^IERICAN  PRACTICE  OF  SURGERY. 

be  certain,  however,  that  they  are  always  combmed.  The  nervous  tissue,  above 
all  structures,  is  particularly  liable  to  undergo  retrograde  changes.  It  is  the 
most  delicate  and  highly  specialized  mechanism  in  the  body.  It  is,  therefore, 
especiallj^  susceptible  to  the  deterioratmg  action  of  a  variety  of  agencies,  while 
its  regenerative  powers  are  but  slight.  Disintegration  and  degeneration  are  con- 
sequently the  most  frequent  and  unportant  pathological  changes  to  which  nerve 
tissue  is  liable.  It  is,  again,  not  always  possible  in  any  given  case  to  determine 
the  etiological  factor  chiefly  or  entirely  to  blame.  Thus,  the  distinction  between 
inflaromatory  and  simple  degeneration  is  often  obscme. 

In  order  to  get  a  clear  appreciation  of  the  degenerations  affecting  the  nervous 
system,  it  is  important  to  bear  in  mind  certain  facts. 

According  to  the  "  neurone  concept "  of  the  histological  structure  of  the  ner- 
vous system,  most  generally  accepted  at  the  present  day,  the  brain  and  cord, 
with  their  continuations,  the  peripheral  nerves,  are  to  be  regarded  in  general  as 
a  peculiar  association  of  highly  specialized  cells,  consisting  of  a  large  cell  body 
with  protoplasmic  processes  (the  ganglion  cell),  from  which  proceeds  a  single, 
long,  and  attenuated  thread  (axis  cylinder  or  neuraxone).  These  together  consti- 
tute the  nemone.  Each  nem'one  is,  so  to  speak,  self-contained,  and  has  no  asso- 
ciation with  adjacent  neurones  save  b}'  contiguity.  The  protoplasmic  processes 
(dendrites)  are  richly  branched  and  interlace  freely  about  the  cell  body.  They 
are  believed  to  be  nutritive  in  their  function,  and  they  convey  impulses  toward 
the  cell  body.  The  axis  cylinders  give  off  collaterals  at  different  levels  and  ter- 
minate in  a  complicated  arborization,  usually  about  another  cell,  at  a  consider- 
able distance  from  their  point  of  origin.  The  impulses  passing  through  them 
are  centrifugal. 

In  general  terms  it  may  be  stated  that  when  a  neiu'axone  is  for  any  cause 
cut  off  from  its  nutrient  centre,  the  ganglion,  it  will  degenerate.  The  process 
begins  at  the  distal  extremity  and  gradually  progresses  backward  to  the  site  of 
the  lesion.  When  the  degeneration  is  confined  to  one  ph3^siological  tract  of  the 
brain  or  cord,  we  speak  of  a  "system"  degeneration.  When  one  or  more  such 
tracts  are  involved,  we  have  a  "combined  sj'stem  degeneration."  Similar  re- 
sults will  follow  any  cause  which  interferes  with  the  conductivity  of  the  nerve 
fibre.  In  what  are  often  called  "primary"  degenerations,  in  which  the  nerve 
bundle  is  acted  upon  directly  and  locally,  certain  tracts  appear  to  be  specially 
picked  out,  namely,  the  sensory  nem'ones  of  the  cord ;  the  central  motor  neu- 
rones, beginning  in  the  pjTamidal  layer  of  the  cerebral  motor  cortex,  extending 
through  the  internal  capsule  into  the  pjTamidal  tracts ;  and  the  peripheral  motor 
neurones,  which  begin  in  the  ganglia  of  the  ventral  cornua,  passing  through  the 
anterior  roots  to  the  muscles.  In  "secondary"  degeneration,  due  to  causes  act- 
ing from  a  distance,  we  have  ascending  and  descending  forms,  according  to  the 
direction  which  the  degeneration  takes  in  the  cord.  Ascending  degeneration 
affects  usually  the  posterior  columns,  the  direct  cerebellar  tract,  and  the  antero- 


DISTURBANCES  OF  NUTRITION.  177 

lateral  tract  of  Gowers.  Descending  degeneration  affects  mainly  the  pyramidal 
tracts. 

There  are  many  causes  of  nerve  degeneration.  Chief  among  them  may  be 
mentioned  old  age,  mechanical  tramna,  pressure,  circulatory  disturbances,  and 
various  intoxications.    In  many  instances  more  than  one  factor  is  at  work. 

Simple  atrophy  of  the  brain  is  particularly  well  exemplified  in  old  age.  The 
organ  as  a  whole  is  diminished  in  size,  the  weight  being  below  the  normal.  The 
wasting  is  most  marked  in  the  frontal  and  vertical  regions.  To  gross  appearance 
the  convolutions  are  small  and  the  sulci  wide.  On  section  the  cortical  gray  mat- 
ter is  seen  to  be  somewhat  thinned.  In  the  more  advanced  cases,  in  addition  to 
these  changes,  the  perivascular  lymph  spaces  are  enlarged,  so  that  the  vessels 
lie  in  wide  channels.  Small  foci  of  degeneration  are  often  to  be  seen  {itat  crible). 
In  such  cases  it  is  not  uncommon  to  find  enlargement  of  the  subarachnoid  space 
and  ventricles,  which  may  be  filled  with  fluid  (hydrops  ex  vacuo).  The  cere- 
bellum, as  a  rule,  escapes. 

Histologically,  the  lesion  is  atrophy  of  the  specific  nerve  elements,  ganglia 
and  medullated  fibres. 

Senile  atrophy  is  to  be  attributed  to  several  causes,  among  which  may  be 
mentioned  the  normal  tendency  to  retrogression  evinced  by  all  tissues  as  ad- 
vanced life  is  approached,  impoverished  nutrition  of  the  body,  and  the  local 
effects  of  a  scanty  blood  supply,  due  to  the  sclerosis  of  the  vessels  which  is  so 
constant  an  accompaniment  of  old  age.  In  accordance  with  the  rule  that  the 
more  highly  developed  structures  are  the  most  liable  to  disease,  it  is  that  portion 
of  the  brain  which  has  to  do  with  the  intellectual  functions  which  suffers  most. 

There  are  other  atrophies,  such  as  those  local  ones  due  to  vascular  changes, 
which  might  be  mentioned,  but  they  are  more  properly  discussed  elsewhere. 

Among  the  commonest  forms  of  degeneration  of  the  spinal  cord  is  that  due 
to  pressure,  the  so-called  "compression  myelitis,"  a  condition  of  much  practical 
interest  to  surgeons. 

As  a  rule,  the  lesion  is  a  transverse  one,  affecting  all  the  tracts  of  the  cord  in 
a  comparatively  restricted  area.  The  usual  causes  are  fracture  of  the  vertebrae, 
tuberculous  caries  of  the  spine,  tuberculosis  of  the  spinal  meninges,  tumors  of  the 
vertebral  canal  or  of  the  cord  itself.  Central  degeneration  may  be  caused  by  an 
accumulation  of  blood  or  fluid  in  the  central  canal.  As  a  result,  we  get  marked 
interference  with  and,  finally,  destruction  of  the  nervous  structures  at  the  site 
of  the  lesion,  with  widespread  ascending  and  descending  degeneration  in  the  as- 
sociated tracts.  The  local  effects  are  to  be  referred  in  part  to  the  direci.  influ- 
ence of  the  pressure,  but  probably  more  to  the  disturbance  of  the  blood  and 
lymph  circulation.    In  some  cases  inflammation  is  also  an  associated  cause. 

The  degeneration  is  first  manifested  in  the  white  substance,  the  fibres  of 
which  swell  up  and  disintegrate.  The  neuraxones  swell  and  become  varicosed, 
and  the  myelin  sheaths  break  down  into  fat.    The  ganglia  are  somewhat  more 

VOL.  I.— 12 


178  .A3IEPJCAX  PRACTICE  OF  SURGERY. 

resistant.  Granular  cells  appear  early  and  in  considerable  numbers.  In  the 
course  of  a  few  daj^s  the  degeneration  reaches  to  the  terminations  of  the  neu- 
rones. Later,  both  the  fibres  and  their  sheaths  ahnost  entirely  disappear,  al- 
though degenerated  and  varicosed  fibres  maj'  be  found  here  and  there,  the  num- 
ber of  fibres  remaining  being  dependent  on  the  extent  and  severity  of  the  original 
cause.  The  place  of  the  destroyed  fibres  is  taken  bj'  newly  foiTned  glia,  which  in 
time  leads  to  contraction  and  sclerosis  of  the  cord.  The  cord  as  a  whole  shrinks, 
becomes  finner,  and  assumes  a  grayLsh  color.  In  some  cases,  where  the  pressure 
can  be  reheved  hj  operation,  the  destroj^ed  fibres  wUl  to  some  extent  be  replaced 
and  fimction  may,  in  part  at  all  events,  be  restored.  The  attempt  must,  how- 
ever, be  made  early. 

Among  other  affections  which  maj'  possiblj^  be  put  in  this  category  of  atro- 
phy may  be  mentioned  disseminated  sclerosis,  anterior  poliom5-eHtis,  progi'es- 
sive  bulbar  parah'sis,  progressive  spinal  muscular  atrophj',  lateral  sclerosis,  pos- 
tero-lateral  sclerosis,  am}-otrophic  lateral  sclerosis,  tabes  dorsalis,  pellagra,  and 
chi-onic  ergotism.  In  how  far  these  are  due  to  simple  atrophj-  and  how  far  to  in- 
flammation, it  is  impossible  to  saj-.  Defective  nutrition,  dependent  on  an  im- 
poverished blood  supply,  is  a  probable  cause  in  some  cases,  as,  for  example,  in 
the  changes  in  the  posterior  and  lateral  columns  of  the  cord  in  pernicious  anse- 
mia.  The  influence  of  toxins  maj'  be  traced  in  other  cases,  as  in  ergotism,  pel- 
lagra. 

ilany  of  these  degenerations  are  important  in  their  results,  as  they  lead  to 
muscular  atrophy,  contractures,  and  even  malformation. 

Atrophy  of  the  peripheral  ner^^es,  as  of  the  cord,  is  not  to  be  dissociated  from 
the  idea  of  degeneration.  It  may  result  from  anj^  cause  which  interrupts  the 
continuity  of  the  fibres  with  their  nutrient  centres,  or  which  destroys  the  trophic 
influence  of  the  centres  themselves.  Destruction  of  the  ganglia  either  in  the 
brain  or  in  the  cord  is  followed  b}'  degeneration  of  the  fibres  proceeding  from 
them.  Severance  of  a  neiwe  tnmk,  as  in  an  accident  or  in  the  course  of  an  ope- 
ration, presstue  exerted  continuoush^  upon  a  ner\-e  tnmk,  and  inflammation  are 
common  causes. 

Degenerative  atrophy  of  a  nerve  fibre  usually  begins  at  the  point  most  re- 
mote from  the  trophic  centre,  and  proceeds  centripetally. 

Tlie  degeneration  which  results  from  severance  of  a  nerve  tnmk,  known  as 
Wallerian  degeneration,  may  be  taken  as  a  tj-pe  of  all  the  rest. 

Wlien  separation  takes  place  by  means  of  a  clean  cut,  all  the  fibres  degener- 
ate practically  simultaneoush-  and,  moreover,  speedily.  Within  twenty-four 
hours  after  the  injury  the  material  composing  the  mediillary  sheaths  becomes 
cloudy  and  less  refractive.  After  about  tliree  daj-s  indentations  and  other  indi- 
cations of  segmentation  are  to  be  seen  in  the  medullary  sheaths  and  sheaths  of 
Schwann,  which  later  break  up  into  droplets  of  myelin  and  fat.  Next,  the  axis 
cylinders  show  eA-idences  of  atrophy  and  gradually  disappear.    They  swell  up. 


DISTURBANCES  OF  NUTRITION.  179 

become  varieosed,  and  vacuolated.  The  interstitial  substance  is  little  if  at  all 
affected.  The  complete  removal  of  the  products  of  the  degeneration  may  be 
long  delayed. 

Eventually  the  whole  of  the  nerve  distal  to  the  point  of  injury  may  be  de- 
stroyed. Degeneration  in  a  centripetal  direction  occiu-s,  but  is  comparatively 
imimportant,  usually  stopping  at  or  close  to  the  nearest  node  of  Ranvier.  Where 
the  injury  has  been  severe,  isolated  fibres  may  degenerate  somewhat  farther,  and 
slight  retrogressive  changes  may  occasionally  be  made  out  in  the  ganglia. 

Somewhat  similar,  if  indeed  not  identical,  changes  may  be  brought  about  by 
the  action  of  circulating  toxins  and  bacteria,  impoverished  nutrition,  and  cer- 
tain circulatory  disturbances.  Systemic  ansemia  and  marasmus  are  important 
in  this  connection.  Endarteritis  and  obstructive  conditions  of  the  blood-vessels 
bring  about  atrophy,  largely  by  cutting  off  nutrition. 

Degeneration  affecting  one  or  more  nerve  trunks  occasionally  arises  in  the 
course  of  diphtheria,  influenza,  typhoid  fever,  typhus,  smallpox,  tuberculosis, 
the  puerperiima,  and  in  chronic  poisoning  with  mineral  substances,  such  as  lead. 
Here,  in  some  cases  at  least,  we  have  the  combined  effect  of  imperfect  nutrition 
and  the  deleterious  action  of  the  toxin. 

Occasionally,  owing  to  some  unknown  infection  or  intoxication,  the  trophic 
ganglia  in  the  anterior  cornua  of  the  spinal  cord  are  destroyed — a  condition 
quickly  followed  by  degenerative  changes  in  the  fibres  proceeding  from  them. 

Secondary  atrophy  of  a  nerve  trimk  may  result  from  inactivity  of  the  mus- 
cles it  supplies,  whether  from  paralysis  or  from  fixation  of  the  part.  The  nerves 
of  special  sense  do  not  escape  this  process.  Thus  the  optic  nerve  and  tract  will 
atrophy  in  cases  of  blindness. 

The  Skin  and  Associated  Structures. — Simple  atrophy  of  the  skin  is  mani- 
fested by  a  wasting  of  almost  all  the  elements  entering  into  its  structure.  It 
may  be  generaUzed  or  localized.  It  may,  again,  be  primary  or  the  result  of 
some  external  pathological  condition. 

As  a  type,  we  may  consider  the  physiological  atrophy  which  takes  place  in 
old  age.  In  this  case  the  cutis  is  thiimed,  the  papillae  are  flattened  and  tend  to 
disappear,  while  the  epidermis  becomes  dry  and  brittle.  Owing  to  the  absorp- 
tion of  the  subcutaneous  fat,  the  skin  is  thro'WTi  into  folds.  The  elastic  tissue 
involutes  and  the  superficial  vessels  are  degenerated.  Brownish  pigment  may 
be  foimd  in  the  cells  of  the  rete  and  about  the  vessels  of  the  cutis.  The  deeper 
portions  of  the  epidermis  are  wasted,  so  that  the  stratum  comeum  is  less  widely 
separated  from  the  papillary  layer.  The  hair  follicles  participate  in  the  process, 
the  hairs  lose  their  pigment,  become  do^vmy,  and  finally  fall  out.  Not  infre- 
quently the  openings  of  the  hair  follicles  become  obstructed,  owing  to  the  ac- 
cumulation of  epidermal  scales,  so  that  the  follicles  may  become  dilated  into 
cysts.  In  the  same  way  the  sebaceous  glands  may  be  involved,  and  hair  follicle 
and  gland  may  be  expanded  into  a  cavity  containing  hairs,  fat,  and  epithelial 


180  AoMERICAN  PRACTICE  OF  SURGERY. 

debris,  the  so-called  atheroma  or  wen.  Eventually  the  sebaceous  glands  may 
disappear.  Not  micommonly  the  superficial  epidermis  is  in  places  heaped  up 
into  scales  (pityriasis  simplex). 

Local  atrophy  is  a  common  condition  brought  about  by  distention  of  the 
skin  from  any  cause.  It  is  found  usually  on  the  abdomen,  breasts,  and  thighs. 
The  commonest  cause  is  pregnancy,  but  tumors,  lactation,  ascites,  and  anasarca 
will  produce  it.  During  pregnancy  the  abdomen  is  covered  with  reddish,  livid 
streaks,  which  after  delivery  are  transformed  into  silvery  lines  or  scars  (linese 
albicantes).  In  such  areas  the  papillse  are  flattened  or  absent,  the  connective- 
tissue  fibres  of  the  corium  are  dissociated,  and  the  elastic  fibres  and  blood-vessels 
are  atrophic. 

Pressure,  as  from  corsets  or  other  clothing,  may  produce  a  similar  effect. 

Local  atrophy  of  this  type  has  been  described  as  occurring  in  certain  acute 
febrile  processes,  notably  typhoid  fever,  and  in  chronic  wasting  disease  where 
the  subcutaneous  fat  has  been  absorbed. 

An  idiopathic,  diffuse,  symmetrical  atrophy  has  been  reported  by  several 
observers. 

Lastly,  atrophy  of  the  skin  may  be  neurotrophic  in  origin,  and  is  met  with 
in  such  conditions  as  lepra  ansesthetica,  neuralgia,  and  neuritis.  The  skin 
over  certain  areas  supplied  by  the  affected  nerves  becomes  thin,  smooth,  and 
shiny,  and  there  may  be  wasting  of  the  glands  and  hair  follicles. 

Lymphatic  Nodes. — Simple  atrophy  of  the  lymphatic  nodes  occurs  as  an  in- 
volution process  in  old  age.  The  same  applies  to  diffuse  lymphadenoid  tissue 
wherever  found.  The  lymphadenoid  structures  appear  to  be  more  active  in  chil- 
dren and  young  adults,  and  physiological  retrogression  occurs  comparatively  early. 

The  lymphoid  cells  are  the  structures  chiefly  affected,  while  the  stroma  is,  on 
the  contrary,  relatively  or  even  absolutely  increased.  The  nodes  are  small,  in- 
creased in  consistency,  and  contain  but  little  juice.  Occasionally  the  lymphoid 
cells  of  the  medullary  portion  disappear  and  the  fibrous  supporting  framework 
imdergoes  fatty  transformation.  The  process  gradually  spreads  to  the  cortex, 
and  the  fundamental  structure  of  the  node  may  in  time  be  entirely  destroyed. 
This  change  is  met  with  chiefly  in  cases  of  chronic  alcoholism.  The  condition 
of  the  lymphatic  nodes  is  of  considerable  importance  in  regard  to  the  question 
of  infection  and  inflammation,  inasmuch  as  these  structures  have  much  to  do  in 
combating  disease  processes  of  this  kind.  As  is  well  known,  infective  processes, 
especially  inflammation  and  suppuration,  tend  to  become  localized  at  the  points 
where  the  nodes  are  most  in  evidence.  Should  they  be  damaged,  either  from 
atrophy  or  from  disease,  they  are  no  longer  competent  to  perform  their  func- 
tions, and  the  dissemination  of  the  infective  process  is  rendered  more  easy. 
The  normal  involution  process  which  lymphadenoid  tissues  undergo  is,  in  a 
certain  sense,  conservative,  since  structures  so  affected  do  not  take  up  bacteria 
to  the  same  extent,  and  hence  are  not  so  liable  to  suffer.     The  involution  of 


DISTURBANCES  OF  NUTRITION.  181 

the  lymphoid  tissue  in  the  appendix  is  given  as  one  of  the  reasons  why  appen- 
dicitis is  less  likely  to  occur  after  middle  life  than  in  the  young  and  vigorous. 

Spleen. — Atrophy  of  the  spleen  occurs  in  old  age  and  in  chronic  wasting  dis- 
ease. It  is  practically  of  no  importance.  The  organ  is  diminished  in  size,  the 
capsule  is  wrinkled  and  opaque,  and  is  thrown  into  folds.  On  section  the  sub- 
stance is  pale  and  the  trabecule;  are  prominent.  The  stroma  may  be  absolutely 
or  relatively  increased,  while  the  pulp  is  diminished. 

Liver. — Simple  atrophy  is  found  in  advanced  age,  in  marasmus,  and  in  the  vari- 
ous cachexias.  A  common  cause  is  pressure,  as  from  corsets.  This  leads  to  the 
formation  of  deep  furrows  and  eventually  accessory  lobes  ("lacing  lobes"). 
Carcinoma  of  the  oesophagus  and  stomach  is  particularly  apt  to  cause  atrophy 
of  the  liver,  probably  from  lack  of  nourishment. 

The  process  affects  chiefly  the  anterior  edge  of  the  liver.  The  parenchyma- 
tous cells  waste,  and  eventually  disappear  vmtil  nothing  is  left  but  the  support- 
ing stroma.  The  edge  of  the  liver  thus  becomes  sharp  and  harder.  In  many 
cases  the  amount  of  pigment  in  the  secreting  cells  appears  to  be  increased  (brown 
atrophy).  Frerichs  has  described  a  special  form  of  atrophy — melangemic  atro- 
phy— said  to  be  due  to  the  blocking  of  the  capillaries  with  black  pigment.  Acute 
yellow  atrophy  of  the  liver  is  presumably  of  an  infective  nature.  It  may  be  mis- 
taken for  the  cholaemia  of  obstructive  jaundice. 

Stomach. — The  part  affected  is  the  mucous  membrane,  which  becomes  thinned 
and  the  glands  granular  and  diminished  in  size.  Atrophy  of  the  stomach 
occurs  in  old  age,  cachexia,  and  marasmus,  and  also  as  a  result  of  chronic 
gastritis. 

Testes. — Atrophy  of  the  testes  occurs  in  old  age  and  as  a  result  of  wasting 
disease.  It  may  also  be  caused  by  pressure,  as  in  cases  of  hydrocele,  ha^mato- 
cele,  varicocele,  hernia,  and  tumors.  It  is  said  to  occur  also  as  a  result  of  injuries 
to  the  cerebellum,  or  of  concussion  of  the  brain,  and  in  paraplegia. 

The  secreting  cells  of  the  tubules  become  fatty,  waste,  and  disappear,  while 
the  connective-tissue  stroma  is  relatively  increased.  A  striking  feature  is  the 
thickening  of  the  walls  of  the  tubules,  which  appear  to  be  swollen,  transparent, 
and  hyaline. 

Prostate. — Simple  atrophy  is  met  with  in  from  twenty  to  thirty  per  cent  of 
old  men.  Occasionally  it  is  met  with  in  the  young,  as  a  result  of  marasmus,  ca^ 
chexia,  castration,  the  pressure  of  retained  urine,  pent-up  secretion,  or  concre- 
tions, and  in  the  impotence  of  tuberculosis. 

In  the  form  due  to  constitutional  causes  the  glandular  structure  is  the  part 
chiefly  affected,  while  in  that  due  to  concretions  the  stroma  suffers  most. 

Ovaries. — Atrophy  of  the  ovaries  occurs  as  a  senile  change  and  as  the  result 
of  chronic  oophoritis.  The  senile  ovary  is  smaller  than  normal,  firm,  nodular, 
and  of  a  grayish  or  pearly  white  appearance.  The  albuginea  is  hard  and  may  be 
several  millimetres  thick.    The  follicles  are  largely  converted  into  small  fibrous 


182  .\,MERIC-\X  PRACTICE  OF  SURGERY. 

masses  (corpora  fibrosa),  with  marked  thickening  of  the  theca.    The  arteries  are 
iisuall}-  thickened  and  hj-aline. 

Mamma. — Simple  atrophy  of  the  glandular  elements  of  the  mammse  occm-s 
as  an  involution  process  after  the  menopause,  and  occasionallj",  but  b}-  no  means 
invariably,  after  removal  of  the  ovaries.  The  wasting  is  often  masked  by  an 
overgro-n-th  of  fat.  Atrophy  is  also  said  to  result  from  the  prolonged  adminis- 
tration of  iodine  or  its  compounds. 

DEGEXERATIOX. 

Closeh'  associated  with  atrophy,  and  in  some  instances  not  to  be  dissociated 
from  it,  are  certain  cellular  changes  which  we  call  degeneration.  The  term  "de- 
generation" is  often  used  in  a  loose  way  to  designate  all  kmds  of  retrograde 
metamorphoses,  but  it  is  also  employed  in  a  specific  and  more  restricted  sense  to 
indicate  a  particular  class  of  retrogressive  phenomena,  which  are  characterized 
bj'  the  formation  of  new  substances  out  of  the  cell  protoplasm.  Such  new  ma- 
terial may  be  retained  within  the  cells  or  discharged  from  them.  An  abnormal 
increase  in  the  production  of  substances  normally  elaborated  in  the  cell  may  also 
possibly  be  included  in  this  category. 

As  we  liaA'e  seen  in  discussing  the  subject  of  growth  and  development,  the 
vital  force  of  cells  is  manifested  in  tliree  ways,  namely,  in  nutrition,  in  reproduc- 
tion, and  in  function.  These,  again,  are  dependent  upon  metabolic  processes  in  the 
cell,  whereby  the  potential  energy  of  the  food  is  transformed  into  actual  work. 
Disturbances  of  metabolism  lead,  on  the  one  hand,  to  abnormal  gro-nth  and  de- 
velopment, and,  on  the  other,  to  various  forms  of  wasting  and  disintegration. 
As  has  been  remarked  above,  we  have  carefully  to  distinguish,  at  least  in  our 
mental  conceptions,  between  atrophy  and  degeneration,  both  of  which  belong 
to  the  great  familj-  of  the  retrograde  metamorphoses.  The  former  connotes  a 
mere  alteration  in  size,  the  latter  a  chemical  sjmthesis  of  new  substances.  It 
may  not  perhaps  be  stricth'  correct  to  state  that  in  atrophy  there  are  no  abnor- 
mal chemical  processes  going  on,  but  at  least  they  are  in  the  backgromid.  In 
degeneration,  chemical  changes  dominate  the  pictiu-e,  and  alteration  in  the  size 
of  a  cell  maj^  or  may  not  take  place.  Frequenth^,  atrophy  and  degeneration  are 
combined. 

As  in  the  case  of  atrophy  and  hj-pertrophy,  we  have  to  distmguish  between 
physiological  and  pathological  degenerations.  To  a  certain  extent  degeneration 
is  natural  and  not  a  manifestation  of  disease.  The  anunal  body,  and,  in  fact,  all 
liATng  organisms,  after  a  preliminary  period  of  gi-owth  and  development,  reach  a 
fastigium,  and  eventually  pass  into  a  state  of  decrepitude,  which  we  call  senility, 
or  old  age,  characterized,  so  far  as  the  cells  are  concerned,  by  inability  to  repair 
the  normal  waste,  imperfect  powers  of  proliferation,  and  diminished  function. 
Each  cell,  each  tissue,  each  complete  organism  has  its  own  life  period,  and  stead- 


DISTURBANCES  OF  NUTRITION.  1S3 

ily  progresses  toward  inevitable  death.  This  deierioration  of  substance  and  im- 
pairment of  function  are  the  concomitants  of  atrophy  and  degeneration,  which 
may  in  many  instances  be  regarded  as  way-stations  en  the  road  to  the  great 
terminus.  The  rate  of  this  progress  is,  however,  not  uniform.  Some  tissues  and 
structures  become  old  and  die  sooner  than  others.  The  involution  of  certain  or- 
gans may,  as  we  have  seen,  occur  during  foetal  life,  in  childliood,  or  in  early  adult 
life.  The  process  of  involution  is  in  part  one  of  atrophy,  and  frequently  one  of 
degeneration  as  well.  Physiological  degeneration  is  the  product  of  normal  retro- 
gressive changes.  Senile  involution  may,  however,  take  place  prematurely.  It 
is  then  pathological.  Many  of  the  degenerative  manifestations  are  not  expres- 
sions of  a  natural,  though  premature,  tendency  to  involution  inherent  in  the 
cells,  but  are  the  result  of  some  deleterious  influence  acting  from  without. 

Death  of  cells  may  be  sudden  or  gradual.  Rapid  death  of  cells  or  tissues, 
without  any  previous  abnormal  changes  in  the  cellular  substance,  is  termed  7ie- 
crosis.  Gradual  death,  preceded  by  diminution  in  size  (atrophy),  by  abnormal" 
intracellular  chemical  processes  (degeneration),  or  by  the  abnormal  deposition 
of  foreign  material  derived  from  a  distance  (infiltration),  is  called  necrobiosis. 
This  distinction  between  sudden  and  gradual  death  is  largely  theoretical,  and  is 
only  valuable  in  that  it  conduces  to  accuracy  of  thought  and  convenience  of  de- 
scription, but  it  should  be  borne  in  mind  that  it  is  not  always  possible  in  practice 
to  draw  this  distinction.  While  necrobiosis  is  invariably  a  sequel  of  atrophy  or 
degeneration,  the  converse  is  not  necessarily  true,  that  pathological  atrophy  and 
degeneration  inevita^bly  lead  to  death  of  the  cell  or  tissue.  Provided  that  the 
cause  is  removed  or  is  not  constantly  acting,  the  condition  may  be  recovered  from. 

It  is  usual  to  classify  the  degenerations — this  term  being  used  in  its 
narrower  sense — according  to  the  nature  of  the  abnormal  substances  produced. 
Strictly  speaking,  true  degeneration  implies  the  manufacture  of  new  chemical 
substances  out  of  the  protoplasm  of  the  cells  themselves.  It  is  convenient,  how- 
ever, to  discuss  at  the  same  time  a  somewhat  similar  process,  that  of  deposit  or 
infiltration,  in  which  the  abnormal  substances  are  brought  to  the  cells  from 
some  distant  part  of  the  body,  or,  it  may  be,  are  introduced  from  without,  and 
are  stored  up  as  so  much  foreign  material  within  the  cell  bodies.  Such  deposit 
may  exist  per  se  or  be  the  result  of  degeneration  in  some  other  part  of  the  body. 
As  a  matter  of  fact,  the  distinction  between  degeneration  and  infiltration  is 
not  always  very  clear,  for  the  same  or  similar  substances  may  be  elaborated 
within  the  cell  out  of  its  own  protoplasm  or  may  be  brought  to  it  from  afar. 
And,  again,  in  the  imperfect  state  of  our  knowledge,  we  are  not  alwaj^s  able 
to  trace  the  exact  course  of  events  in  any  given  case.  It  is  generally  held  that 
some  substances,  such  as  fat,  melanin,  and  glycogen,  may  be  of  the  nature  at 
one  time  of  a  degeneration,  at  another,  of  a  deposit. 

Warthin  classifies  the  degenerations  and  infiltrations  as  follows: 

True  Degeneration.— 1.  Cloudy  swelling.     2.  Fatty  degeneration.     3.  Hy- 


184  AMERICAN  PRACTICE  OF  SURGERY. 

dropic  degeneration.  4.  Colloid  degeneration.  5.  Colloid-like  bodies.  6.  Mucin. 
7.  Pseudo-mucin.  8.  Cholesterin.  9.  Epithelial  hyalin.  10.  Cornification.  11. 
Pigments  formed  by  cell  activity.    12.  Glycogen. 

Deposits. — 1.  Fat.  2.  Amyloid.  3.  Hyalin.  4.  Calcification.  5.  Uric  acid, 
urates.  6.  Cholesterin,  cystin,  xanthin,  etc.  7.  Glycogen.  8.  Pigment.  9.  Ex- 
trinsic substances. 

Cloudy  Swelling. — Cloudy  swelling  (granular,  albuminous,  or  parenchyma- 
tous degeneration)  is  the  commonest  of  the  true  degenerations.  Here  the  cyto- 
plasm is  broken  up  into  fluid  and  granules  of  an  albuminous  material.  The  con- 
dition is  found  chiefly  in  the  secreting  cells  of  glands  and  in  muscle,  but,Js  said 
to  affect  also,  though  to  a  less  degree,  the  connective-tissue  stroma  and  wan- 
dering cells.  Organs  so  affected  are  somewhat  swollen,  pale,  doughy,  and  less 
glistening  than  normal.  In  severe  cases  they  have  a  parboiled  appearance, 
which  has  been  compared  to  raw  fish. 

Microscopically,  the  parenchymatous  cells  are,  as  the  name  would  imply, 
swollen,  cloudy,  or  opaque,  and  the  nucleus  may  be  indistinct  or  even  invisible. 
The  cloudiness  is  due  to  the  presence  of  innumerable  fine  particles  in  the  cyto- 
plasm. These  particles  are  so  thickly  placed  that  the  normal  structure  and 
granulation  of  the  cell  body  is  obliterated.  The  particles  are  not  fat,  since  they 
do  not  stain  with  osmic  acid  or  Sudan  III.  They  dissolve  on  the  addition  of 
weak  acetic  acid  or  caustic  potash,  inasmuch  as  they  are  converted  into  acid  or 
alkali  albumin,  which  is  soluble.  The  condition  is  best  seen  in  fresh  specimens 
cut  on  the  freezing  microtome.  In  severe  cases  the  chromatin  of  the  nuclei 
breaks  down  and  is  diffused,  and  the  cell  may  even  disintegrate  into  a  fine  gran- 
ular debris  (see  Fig.  65). 

Cloudy  swelling  occurs  in  all  infectious  fevers,  in  various  intoxications,  and  in 
cachexias.  Thus  it  is  often  found  in  typhoid  fever,  variola,  diphtheria,  scarlatina, 
and  septicaemia,  in  acute  nephritis,  and  in  poisoning  from  chemical  substances, 
such  as  bichloride  of  mercury,  carbolic  acid,  arsenic,  and  cantharides.  The  con- 
dition is,  moreover,  not  to  be  regarded  as  the  result  of  high  temperature  only, 
for  it  is  met  with  in  many  afebrile  conditions,  such  as  carcinosis.  Much  more 
likely,  it  is  to  be  attributed  to  the  influence  of  some  circulating  toxin.  The  ex- 
tent of  the  process  is  probably  directly  proportional  to  the  amount  of  the  circu- 
lating toxins. 

The  exact  nature  of  cloudy  swelling  is  not  absolutely  clear.  Virchow,  who 
first  described  it,  found  it  in  cases  of  parenchymatous  inflammation,  but  it  is 
undoubtedly  often  to  be  found  in  organs  that  are  not  inflamed.  Nevertheless, 
it  is  true  that  in  many  instances  it  is  the  earliest  manifestation  of  inflammation. 
There  is  also  a  close  relationship  between  cloudy  swelling  and  fatty  degenera- 
tion, for  the  two  are  often  combined,  and,  if  the  cause  acts  for  a  prolonged  period, 
the  former  passes  imperceptibly  into  the  latter.  If  the  condition  be  not  extreme, 
recovery  is  possible,  with  complete  restitutio  ad  integrum. 


DISTURBANCES  OF  NUTRITION.  185 

Fatty  Degeneration. — It  is  generally  taught  that  in  this  form  of  degeneration 
the  fat  is  formed  out  of  the  albuminous  material  of  the  cell  body.  As  we  shall 
see,  there  are  some  grounds  for  doubting  this.  The  structiu-es  usually  affected  are 
the  parenchymatous  organs,  such  as  the  liver  and  kidneys,  but  the  muscles  and 
connective  tissue  are  by  no  means  infrequently  involved.    All  cells,  moreover, 


Fig.  65. — Cloudy  Swelling  of  the  Kidney.  The  secreting  cells  are  swollen  and  cloudy;  the  nuclei 
stain  badly;  the  lumina  of  the  tubules  are  irregular.  {Leitz  obj.  No.  7.)  {From  the  author's  private 
collection.) 

which  are  out  of  their  environment  or  are  cut  off  from  their  source  of  nourish- 
ment, may  undergo  fatty  degeneration,  as,  for  example,  leucocytes  (pus  cells) 
and  carcinoma  cells. 

The  affected  organs  are  usually  diminished  in  size,  soft,  friable,  or  doughy, 
and  of  a  pale  yellowish  or  yellowish-white  color.  On  section  the  surface  is  often 
greasy.  The  condition  may  be  uniformly  distributed  through  the  organ  or  may 
occur  in  specks,  patches,  or  streaks.  A  well-known  example  of  this  is  the  so- 
called  "thrush-breast"  heart,  found  often  in  pernicious  anaemia  and  in  some  fe- 
brile conditions.    The  affected  organ  is  usually  flabby  and  lacking  in  consistency. 

Microscopically,  the  cell  protoplasm  contains  nunlerous  small,  highly  refrac- 
tile,  colorless  droplets.  These  are  very  irregular  in  size  and  shape,  in  some  cases 
being  extremely  minute,  in  others,  where  the  smaller  droplets  have  become  con- 
fluent, forming  larger  drops,  which  may  almost  completely  fill  the  cell.  The 
droplets  are  insoluble  in  acetic  acid,  but  are  soluble  in  alcohol  and  ether.  With 
osmic  acid  they  take  a  brownish  or  blackish  color  (see  Fig.  66).  When  treated 
with  Sudan  III  the  finer  particles  stain  a  golden  yellow;  the  larger  are  more 
of  a  carmine  color. 


186  A.MERICAN  PRACTICE  OF  SURGERY. 

In  general,  fatty  degeneration  occurs  tinder  the  same  conditions  as  cloud}' 
swelling.  Given  a  sufficient  intensity  in  the  cause  or  a  sufficient  length  of  time, 
and  cloudy  swelling  will  pass  into  fatty  degeneration.  We  find,  then,  fatty  de- 
generation in  acute  infectious  diseases,  such  as  typhoid,  pneumonia,  diphtheria, 
scarlatina,  septicaemia,  erysipelas,  etc.,  in  poisoning  with  phosphorus,  camphor, 
arsenic,  alcohol,  and  chloroform.  In  regard  to  the  last-mentioned  agent,  it  may 
be  remarked  that  several  cases  of  acute  fatty  degeneration  of  the  liver,  followed 
by  death,  have  been  recently  reported  in  connection  with  chloroform  ansesthe- 
sia.  This  result  is  fovmd  in  delicate  or  debilitated  persons,  especially  those  who 
have  been  suffering  from  chronic  bone  disease.  Besides  the  causes  mentioned, 
anaemia  of  all  kinds,  chronic  congestion,  diminished  blood  supply,  may  on  occa- 


FiG.  66. — Fatty  Degeneration  of  the  Heart.  Specimen  stained  with  osmic  acid.  Fat  is  black. 
{Leitz  obj.  No.  7.)      (From  the  author's  private  collection.) 

sion  produce  it.  Acute  and  chronic  ana:>mia  from  hemorrhage,  pernicious  anae- 
mia, leuka?mia,  and  the  local  anaemia  caused  by  sclerosis  of  vessels,  embolism, 
or  thrombosis,  are  important  in  this  connection. 

The  conditions  at  the  back  of  fatty  degeneration  appear  to  be  impaired  vital- 
ity of  the  cells,  together  with  changes  in  the  nutrition.  The  chief  factor  is  be- 
lieved to  be  deficient  oxygenation  of  the  cells.  This  results  in  the  cell  protoplasm 
being  broken  down  partly  into  fat  and  partly  into  nitrogenous  substances  which 
are  excreted  by  the  urine. 

Diminished  oxygenation  may  be  produced  by  a  deficiency  in  the  cjuantity  of 
blood  supplied  to  a  part  or  by  defective  quality.  By  some,  the  albuminous  and 
fatty  changes  so  often  found  in  febrile  affections  are  regarded  as  due  to  the  func- 
tional increase  necessary  to  the  production  of  the  increased  heat,  especially  in 


DISTURBANCES  OF  NUTRITION.  187 

regard  to  the  organs  which  are  most  directly  concerned  in  the  maintenance  of  the 
bodily  heat,  viz.,  the  heart  and  the  liver.  Probably,  however,  the  direct  influence 
of  bacterial  toxins  and  the  toxic  products  of  disturbed  motabolism  are  of  more  im- 
portance. Possibly,  too,  increased  functional  activity,  amounting  to  overstrain, 
may,  as  in  the  case  of  atrophy,  lead  to  retrogressive  changes  of  this  character. 
This  is  rendered  likely  by  the  fact  that  fatty  degeneration  is  often  chiefly  local- 
ized to  organs  which  are  apt  to  be  overworked :  the  heart,  from  pumping  an  in- 
creased amount  of  blood — blood,  moreover,  which  may  be  deteriorated  in  cjual- 
ity;  and  the  liver  and  kidneys,  which  have  to  excrete  the  deleterious  substances. 

When  we  come  to  discuss  the  essential  nature  of  the  process  resulting  in  fatty 
degeneration,  we  are  led  into  somewhat  uncertain  paths.  It  has  been  almost 
imiversally  taught  by  physiologists  that  fat  is  formed  from  proteid  material. 
The  pathologists  have  accepted  this,  and  have  assumed  that  in  fatty  degenera- 
tion the  transformation  is  at  the  expense  of  the  cellular  substance.  Taylor, 
Pflueger,  Athanasiu,  and  others  strenuously  combat  this  view,  holding  that  it 
has  never  been  demonstrated  to  be  possible  from  a  chemical  point  of  view.  The 
■question  must  in  the  mean  time,  perhaps,  be  left  open.  Bauer's  experiments 
would,  on  the  one  hand,  indicate  the  possibility  of  the  older  view.  He  found 
that  he  could  produce  extensive  fatty  degeneration  in  dogs  by  feeding  them  with 
phosphorus,  in  cases  where  they  had  previously  lost  their  fats  through  a  course 
of  starvation.  Lindemann  and  others  also  think  that  the  marked  cytoplasmic 
and  nuclear  changes  in  fatty  degeneration  are  sufficient  evidence  of  the  origin 
of  the  fat  from  the  cell  protoplasm.  On  the  other  hand,  even  if  it  be  true  that 
fat  is  formed  within  degenerated  cells,  it  is  open  to  belief  that  it  may  possibly  be 
formed  out  of  carboh3^drate  substances  present  in  the  cells.  It  can  hardly  be 
■denied,  however,  that  cloudy  swelling  is  due  to  a  chemical  transformation  of  the 
cellular  proteid;  and,  inasmuch  as  cloudy  swelling  and  fatty  degeneration  arise 
•under  identical  conditions  and  are  so  frequently  combined,  the  one  condition 
often  passing  imperceptibly  into  the  other,  the  proteid  origin  of  the  fat  does  not 
appear  by  any  means  imlikely.  In  view,  howeA'er,  of  the  unsettled  state  of  the 
controversy,  it  would  perhaps  be  more  strictly  correct  to  speak  of  "  fatty  degen- 
■eration"  as  ''a  cell  degeneration  associated  with  the  formation  of  fat." 

Fatty  Infiltration. — Fatt}'  infiltration  may  be  defined  as  a  deposit  of  fat  in  the 
cells  of  an  organ  or  tissue,  without  any  essential  change  in  their  structure. 

Under  ordinary  circumstances  fat  is  stored  up  in  the  cells  in  various  parts  of 
the  body.  It  acts  as  a  protection  against  external  cold  and  injury,  as  a  lubri- 
cant, and  as  a  potential  source  of  energy.  The  amount  of  fat  present  in  any 
given  case  depends  upon  the  quantity  produced  in  the  processes  of  assimilation 
and  nutrition  and  the  amount  consumed  in  the  oxidation  incident  to  metabo- 
lism. Fat  may  be  brought  to  the  body  in  food,  being  emulsified  and  carried 
from  the  intestines  by  the  lacteals  and  lymphatics  and  being  stored  up  in  the 
various  cells  of  the  body,  notably  those  of  the  liver.    Or,  again,  it  may  be  pro- 


188  AMERICAN  PRACTICE  OF  SURGERY. 

duced  by  cellular  activity  from  the  carbohydrate  and  proteid  constituents  of  the 
food.  Therefore,  an  excessive  amount  of  fat  may  accunmlate  in  the  system,  if 
there  be  an  abnormal  amount  ingested  or  produced,  or  if  there  be  a  deficient 
consumption  of  the  fat.  Or  both  factors  may  be  at  work.  Up  to  a  certain  point 
the  process  of  fat  deposit  is  physiological,  and  we  must  be  prepared  to  admit 
wide  variations  in  its  extent  as  being  within  normal  limits.  When  it  becomes 
excessive  we  speak  of  obesity,  adiposity,  lipomatosis,  or  polysarcia.  The  process, 
however,  is  in  general  the  same,  whether  under  physiological  or  under  pathologi- 
cal conditions.  Wliat  may  be  termed  digestive  fatty  infiltration  is  well  seen  in  the 
liver  after  a  meal.  On  the  other  hand,  when  an  animal  is  deprived  of  food  for 
some  time  the  liver  becomes  destitute  of  fat.  An  abnormal  amount  of  fat  may 
be  laid  down  if  there  be  an  excess  of  fat  in  the  food  ingested.  According  to  the 
older  view,  this  fat  was  carried  mechanically  to  the  liver  and  deposited  there. 
There  are  reasons,  however,  for  thinking  that  the  process  is  not  so  simple  as  this. 
The  proportions  of  the  various  constituents  of  fat  vary  in  the  case  of  different 
animals.  Now  if  you  feed,  for  example,  a  dog  on  palmitin,  this  will  be  trans- 
formed and  deposited  in  the  various  cells  in  the  form  of  fat  normally  character- 
istic for  the  dog.  This  can  be  explained  only  by  assuming  the  active  interfer- 
ence of  the  cells  themselves.  Therefore,  fatty  infiltration  is  not  a  mere  deposit 
of  fat  in  passive  receptacles,  but  a  true  metabolic  process,  in  which  the  cells 
play  a  most  important  part.  What  happens  is  probably  this :  The  fat  ingested 
is  immediately  oxidized  and  employed  for  the  requirements  of  the  body;  the 
fat  that  is  deposited  is  the  result  of  the  metabolism  of  the  carbohydrates  and 
proteids  brought  to  the  cells.  Whichever  view  is  accepted,  it  is  evident  that 
fatty  infiltration  differs  essentially  from  fatty  degeneration.  In  the  former  the 
fat  is  not  produced  at  the  expense  of  the  cell  protoplasm,  but  from  material  im- 
ported to  the  cells  from  without. 

Fat,  again,  may  accumulate  owing  to  deficient  fat  consumption.  Here  all 
conditions  which  lead  to  imperfect  oxidation  are  important.  Probably  of  this 
nature  is  the  obesity  which  comes  on  with  middle  age.  Diminished  work  on 
the  part  of  the  cells,  sluggish  respiration,  chronic  antemia,  alcoholism — all  may 
play  a  part. 

In  some  cases  the  normal  balance  which  should  exist  between  fat  production 
and  fat  consumption  is  upset  without  obvious  cause.  The  food  is  of  suitable 
quantity  and  quality,  and  the  waste  appears  to  be  going  on  normally,  and  yet, 
in  spite  of  this,  fat  accumulates  in  excess.  Here  there  are  abnormal  metabolic 
processes  going  on,  the  exact  nature  of  which  we  do  not  understand.  Undoubt- 
edly in  some  instances  there  is  some  inherited  peculiarity.  In  others  the  tend- 
ency is  acquired.  It  is  interesting  to  note  in  this  connection  the  relationship 
which  exists  between  the  sexual  system  and  fat  production.  For  example,  in 
young  girls  fat  tends  normally  to  be  deposited  in  certain  situations  with  the  on- 
set of  puberty.    Women  not  uncommonly  become  stout  after  the  menopause  or 


DISTURBANCES    OF   NUTRITION.  189 

on  removal  of  the  ovaries.  Eunuchs  are  also  often  obese.  Conversely,  young 
women  who  become  inordinately  fat  are  frequently  sterile. 

Fatty  infiltration  may  be  local  or  general.  Local  lipomatosis  is  to  a  certain 
extent  to  be  regarded  as  complementary  in  certain  cases.  Thus,  the  fat  is  often 
increased  about  atrophic  or  wasted  organs.  For  example,  the  fat  is  increased 
about  a  contracted  kidney,  in  the  interstitial  substance  of  the  atrophied  heart, 
and  between  the  bundles  of  atrophic  muscle.  Multiple,  circumscribed,  and  often 
symmetrically  disposed,  fatty  tumors — lipomata — are  probably  to  be  ascribed 
to  abnormal  cellular  activity.  Adiposis  dolorosa  (Dercum)  also  comes  under  this 
category. 

General  obesity  is  not  uncommon.  Here  the  excessive  deposit  of  fat  takes 
place  first  at  the  points  where  fat  is  normally  stored,  namely,  in  the  subcutane- 
ous and  subserous  connective  tissue,  in  the  liver,  in  the  bone-marrow,  and,  later, 
in  unusual  situations,  such  as  in  the  wall  of  the  heart,  in  the  interstitial  sub- 
stance of  the  voluntary  muscles,  and  in  the  submucous  connective  tissue. 

The  gross  appearance  of  a  fattily  infiltrated  organ  is  characteristic.  In  the 
case  of  the  heart,  the  organ  is  enlarged,  mainly  from  a  great  deposit  of  fat  in  the 
epicardium.  On  cutting  through  the  wall,  this  fat  can  be  traced  in  the  form  of 
pads  and  streaks  between  the  muscle  bundles.  In  places,  especially  near  the 
apex,  there  may  be  but  little  muscle  left. 

In  fatty  infiltration  of  the  liver,  the  organ  is  enlarged,  unlike  what  occurs  in 
fatty  degeneration.  The  edges  are  rounde'd,  and  the  tissue  is  doughy,  pitting 
on  pressure.  In  color  it  is  yellow  or  yellowish- white.  On  section  it  is  soft,  fri- 
able, and  greasy.  Globules  of  fat  can  be  scraped  off  with  the  knife.  In  ad- 
vanced fatty  infiltration  the  liver  may  actually  float  when  placed  in  water. 
These  examples  illustrate,  moreover,  the  two  types  of  fatty  infiltration.  In  the 
former  the  fat  is  deposited  in  the  interstitial  connective  tissue;  in  the  latter, 
within  the  parenchymatous  cells. 

Microscopically,  the  heart  will  show  large  masses  of  adipose  tissue  lying  be- 
tween the  muscle  bundles  (see  Fig.  67).  In  the  liver  the  parenchymatous  cells 
show  no  structural  changes  other  than  those  due  to  the  mere  presence  of  the 
fat.  In  the  early  stages  the  cells  contain  small  droplets  of  fat,  which  later 
coalesce  to  form  larger  globules,  almost  or  quite  filling  up  the  cell.  In  this  way 
we  get  a  large  oil  globule,  surrounded  by  a  thin  shell  of  protoplasm,  the  nucleus 
of  the  cell  being  crowded  to  one  side,  which  gives  the  cell  a  characteristic 
signet-ring  appearance.  Where  fat  globules  are  present  within  the  specific 
cells  of  an  organ,  it  is  not  always  easy  to  decide  whether  we  have  to  do  with 
fatty  degeneration  or  with  fatty  infiltration.  In  the  former  we  can,  on  careful 
study,  usually  make  out  degenerative  changes  in  the  cytoplasm  and  in  the  nu- 
cleus. The  cells  are  also  usually  atrophic,  while  in  fatty  infiltration  the  cells 
are  larger  than  normal. 

Fatty  infiltration,  like  fatty  degeneration,  may  result  in  serious  interference 


190  AMERICAN  PRACTICE  OF  SURGERY. 

with  function.  General  obesity  leads  to  inhibition  of  movement,  sluggish  res- 
piration, weak  heart  action,  and  to  some  extent  it  slows  metabolism  generally. 
Fatty  infiltration  of  the  heart  in  time  produces  muscular  insufficiency  and  oc- 
casionally rupture  of  the  wall.  The  liver,  on  the  other  hand,  is  able  to  perform 
its  functions  comparatively  well,  even  in  the  presence  of  advanced  fatty  deposit- 
These  results  are  brought  about  in  part  by  the  mechanical  effect  of  the  deposited 


Fig.  67. — Fatty  Infiltration  of  the  Heart  Muscle.  A  mass  of  fat  can  be  seen  embedded  in  the  walL 
{^Lertz  obj.  No.  '6.)      {From  the  author's  private  cotlectwn.) 

fat,  and  in  part  by  the  secondary  atrophy  of  the  specific  cells  due  to  pressure  and 
imperfect  nutrition. 

Hydropic  Degeneration. — This  form  of  degeneration  is  characterized  by  the 
partial  liquefaction  of  the  cellular  substance,  resulting  in  the  formation  of  clear 
vacuoles  withm  the  cell.  The  degeneration  may  take  place  both  in  the  cyto- 
plasm and  m  the  nucleus.  The  nucleus  may  be  so  ballooned  out  as  to  resemble 
a  little  sac  filled  with  colorless  fiuid.  Hydropic  degeneration  is  the  first  stage  of 
colliquative  necrosis,  and  is  also  found  in  vesication  of  the  skin,  inflammation, 
and  in  the  cells  of  tumors.  The  cell  and  its  nucleus  stain  badly,  thus  indicating 
that  It  is  a  retrograde  process. 

Colloid  Degeneration. — Colloid  is  a  senn-solid,  translucent,  homogeneous,  and 
structureless  substance,  of  a  yellowish  or  brownish  color.  In  general  appearance 
it  resembles  stiff  glue.  Colloid  is  found  normally  within  the  follicles  and  lym- 
phatics of  the  thyroid  gland  and  in  the  pituitary  body.  It  bears  a  general  rela- 
tionship, so  far  as  external  appearance  goes,  to  mucin,  hyalin,  and  amyloid. 
Chemically,  it  differs  from  these  in  some  particulars.  Its  exact  composition  is 
unknown,  but  it  is  believed  to  be  an  albuminous  body  containing  thyroidLa. 


DISTURBANCES  OF  NUTRITION.  191 

The  material  does  not  swell  up  in  water,  is  not  precipitated  by  alcoliol  or  acetic 
acid,  and  is  stained  orange-red  by  Van  Gieson's  method. 

Pathologically  (see  Fig.  68),  colloid  is  found  in  increased  amount  in  certam 
cases  of  enlarged  thyroid  (colloid  goitre),  and  in  some  tumors  of  the  thyroid. 
Material  resembling  thyroidal  colloid  is  at  times  found  within  the  kidney  (col- 
loid casts),  in  cysts  of  the  kidney  or  ovary,  in  the  prostate  and  parotid,  and  in 
some  carcinomata.  Whether  it  is  identical  with  true  colloid  is  perhaps  doubt- 
ful. Colloid  and  colloidal  material  must  in  all  probability  be  regarded  as  prob- 
ucts  of  epithelial  cell  activity. 

Mucinous  Degeneration. — Mucus  is  a  homogeneous,  transparent,  slightly  ropy 
material,  the  chemical  constitution  of  which  is  not  exactly  known.  Probably  a 
number  of  substances,  in  general  resembling  one  another,  but  differing  slightly 
in  composition,  are  included  imder  the  term  mucus.  The  principal  ones  known 
at  present  are  mucin  and  pseudo-mucin.  Mucin  contains  nitrogen  and  sulphur, 
swells  in  water,  is  dissolved  in  alkaline  fluids,  is  precipitated  by  alcohol  and 
acetic  acid.  It  is  non-diffusible.  Pseudo-mucin  dissolves  in  water  and  is  not 
precipitated  by  acetic  acid.    From  both  mucin  and  pseudo-mucin  a  carbohydrate 


Fig.  68. — Excessive  Production  of  Colloid  m  the  Thyroid  Gland — Colloid  Struma.  {Leitz  obj. 
No.  3.)      {From  the  author's  private  coiiection.) 

may  be  obtained,  indicating  that  they  are  to  be  regarded  as  glyco-proteid  in 
nature. 

Mucus  is  found  normally  as  a  secretion  of  mucous  membranes  and  mucous 
glands,  in  joints,  tendon  sheaths,  and  bursse,  and  forms  the  Wharton's  jelly  of  the 
umbilical  cord.  In  the  case  of  the  mucous  membranes,  mucus  seems  to  be  the 
special  secretion  of  certain  cells,  called  from  their  appearance  "goblet  cells." 


192  AMERICAN  PRACTICE  OF  SURGERY. 

These  cells,  when  in  an  active  condition,  contain  a  clear,  colorless,  transparent, 
oval  globule,  which  eventually  is  extruded  upon  the  surface  of  the  membrane  or 
into  the  lumina  of  the  glands. 

Pathologically,  mucus  is  formed  in  considerable  quantities  in  various  condi- 
tions. Thus,  in  inflammation  of  mucous  membranes,  there  is  an  excessive  pro- 
duction of  mucus  from  the  superficial  epithelium  and  the  glands.  The  number 
of  goblet  cells  appears  also  to  be  increased.  Not  only  so,  but,  unlike  what  oc- 
curs in  normal  secretion,  the  cytoplasm  and  even  the  nucleus  of  these  cells  un- 
dergo mucinous  degeneration  leading  to  complete  destruction  of  the  affected 
cells.  The  globules  of  mucin  coalesce  and  we  get  a  continuous  sheet  of  stringy 
mucus  covering  over  the  inflamed  surface  (catarrhal  inflammation).  Pus  cells, 
if  present  in  the  exudate,  may  in  their  turn  undergo  the  same  transformation. 
In  such  cases  the  presence  of  mucus  in  excess  is  to  be  regarded  as  protective  in 
its  nature,  for,  although  non-bactericidal,  mucus,  by  its  mere  presence,  inter- 
feres with  the  action  of  pathogenic  bacteria,  and  in  the  course  of  its  excretion 
tends  to  flush  out  the  diseased  area.  Mucoid  degeneration  is  also  not  infre- 
quently met  with  in  the  epithelial  cells  of  tumors,  especially  carcinomata,  in- 
volving the  mucous  membranes.  In  such  cases  large  masses  of  carcinomatous 
tissue  may  be  converted  into  mucin.  Such  tumors  have,  on  section,  a  sticky, 
gelatinous  appearance.  The  epithelial  cells  in  large  part  disappear,  and  their 
place  is  taken  by  a  fibrillar,  loosely  arranged  material,  which  strikes  a  bluish 
tinge  with  hsematoxylin.  Pseudo-mucin  is  found  in  a  large  number  of  ovarian 
cystadenomata. 

Mucinous  degeneration  is  also  to  be  observed  in  connection  with  mesoblastic 
structures.  Here  the  intercellular  substance  loses  its  fibrillar  character  and  is 
converted  into  mucin.  This  transformation  occurs  in  connective  tissue,  carti- 
lage, bone,  bone-marrow,  and  fat.  The  connective-tissue  framework  of  some 
sarcomata  and  carcinomata  may  show  the  change.  Microscopically,  in  such  cases 
we  find  bipolar  or  stellate  cells,  with  long  processes,  floating  in  a  loose,  struc- 
tureless, colorless  matrix.  The  majority  of  nasal  polyps  are  mucinous  in 
character.  In  myxoedema,  a  curious  disease  due  to  inadequacy  of  the  thyroid 
secretion,  there  appears  to  be  a  mucoid  metamorphosis  of  the  subcutaneous  tis- 
sues. 

Cholesterin. — Plates  of  cholesterin,  apparently  the  product  of  degeneration, 
are  found  in  atheromata,  cysts,  the  walls  of  sclerotic  vessels,  old  extravasations, 
and  purulent  exudates.  In  such  cases  it  appears  to  be  a  by-product  in  the  proc- 
ess of  fatty  degeneration.  Cholesterin  is  found  in  the  form  of  thin,  rhombic 
plates,  frequently  having  a  small  rhomb  taken  out  of  one  corner. 

Epithelial  Hyalin. — A  number  of  substances,  bearing  a  general  resemblance 
to  colloid  or  hyaline  material,  have  been  grouped  under  this  head.  Probably 
they  are  not  all  of  identical  chemical  composition.  Warthin  would  restrict  the 
term  "epithelial  hyalin"  to  the  degeneration  products  of  epithelial  cells,  which 


DISTURBANCES  OF  NUTRITION.  193 

resemble  the  hyalin  of  connective  tissue  in  tliat  they  stain  with  fuehsin.  In  this 
category  would  come,  therefore,  the  hyaline  granules  and  globules  found  in  car- 
cinoma cells.  These  have  been  thought  to  be  parasites,  but  are  really  due  to 
degeneration  of  the  epithelial  cells. 

Corniflcation. — Cornification  occurs  normally  in  the  skin.  Excessive  corni- 
fication  (hyperkeratosis)  takes  place  exceptionally.  The  condition  may  be  con- 
genital, as  in  ichthyosis  congenita,  or  acquired.  Irritation  of  the  skin  of  all  kinds, 
mechanical  or  inflammatory,  may  result  in  hyperkeratosis.  Familiar  instances 
are  warts,  callosities,  and  corns.  Cornification  may  also  occur  pathologically  in 
parts  of  the  body  where  it  normally  should  not  take  place  at  all  or  only  to  a  trifling 
extent.  Thus,  the  ducts  of  the  cutaneous  glands  may  be  affected  and  even 
blocked.  Mucous  membranes  also,  such  as  those  of  the  mouth,  vagina,  urinary 
passages,  middle  ear,  and  mastoid  cells,  may  on  occasion  be  transformed  into 
skin-like  structures.  Keratohyalin  is  also  produced  in  certain  tumors  of  the  skin, 
brain,  and  meninges.  In  such  cases  the  process  is  a  true  cell  degeneration,  the 
horny  material  being  formed  by  the  cells  at  the  expense  of  their  nuclei.  The 
nuclei  shrink  and  ultimately  disappear. 

Pigmentation  from  Cellular  Activity. — The  pigments  found  in  the  body  are 
derived  from  various  sources.  They  may  be  the  result  of  cellular  activity — 
autochthonous  or  metabolic  -pigments;  they  may  arise  from  changes  in  the  blood, 
with  liberation  and  modification  of  the  hajmoglobin — hematogenous  -pigments; 
they  may  be  derived  from  the  bile  which  has  been  absorbed  into  the  tissues — 
jaundice  or  icterus;  or  they  may  be  foreign  material  imported  from  without — 
extraneous  pigments. 

At  the  present  moment  we  are  concerned  exclusively  with  the  metabolic  pig- 
ments. Pigment  normally  is  found  in  many  parts  of  the  body  in  the  form  of 
yellowish,  brown,  or  black  granules  within  the  cells  or  in  the  intercellular  sub- 
stance. Thus  it  is  present  in  the  deeper  layers  of  the  rete  Malpighii  of  the  skin, 
in  the  choroid  and  retina,  in  the  hair,  and  in  the  ganglion  cells  of  the  central 
nervous  system.  It  is  found  also  in  the  connective  tissue  of  the  pia  mater,  the 
heart  and  other  muscles,  the  kidneys  and  suprarenals.  According  to  their  chem- 
ical peculiarities,  pigments  are  called  melanin,  haemofuscin,  and  lipochrome. 

The  normal  amount  of  pigment  may  be  increased  under  certain  physiological 
and  pathological  conditions.  The  pigmentation  of  the  skin  becomes  more  in- 
tense in  certain  regions  during  pregnancy.  Sunburn  results  in  increased  colora- 
tion of  the  affected  part.  Freckles  are  a  form  of  increased  pigmentation.  In 
Addison's  disease  there  is  an  excessive  formation  of  pigment  in  the  skin  and 
mucous  membranes.  The  most  extreme  examples  of  pathological  pigmentation 
are  found  in  certain  moles  of  the  skin  and  in  the  melanotic  sarcomata  and  car- 
cinomata.  In  these  growths  the  pigment  lies  both  within  the  cells  and  in  the 
intercellular  substance  in  the  form  of  fine  brownish  or  blackish  granules.  Some 
of  these  tumors  are  coal  black.    In  such  cases  the  urine  may  contain  substances 

VOL.  I.  —  IS 


194  AMERICAX  TRACTICE  OF  SURGERY. 

which  turn  black  on  exposure  to  the  air  (melanuria).  In  the  examples  cited  it  is 
believed  that  the  pigment  results  from  cellular  activity  of  a  special  nature. 
Koelliker  holds  that  in  the  skin  the  pigment  is  carried  by  wandering  connective- 
tissue  cells  (chromatophores),  which  send  processes  between  and  into  the  epi- 
thelial cells,  and  there  deposit  their  pigment.  The  source  of  these  chroma- 
tophores is  quite  unknown.  In  what  way  the  pigment  is  produced  is  also 
unknown.  It  would  seem  probable,  however,  that  it  is  elaborated  by  the  cells 
from  albuminous  substances. 

Besides  the  melanin  found  in  the  cases  just  referred  to,  we  have  hfemofuscin, 
supposed  to  be  identical  chemically  with  liEematoidin.  It  is  found  occasionally 
in  the  heart  and  in  the  unstriped  muscle  of  the  intestine. 

Lipochrome  is  a  pigment,  or  rather  a  class  of  pigments,  of  obscure  nature, 
found  in  the  corpus  luteum  of  the  ovary  as  a  yellow-colored  fat  (lutein),  and  in 
the  rare  tvunor  known  as  the  chloroma,  which  is  of  a  pale  greenish  color.  The 
so-called  xanthoma  of  the  skin  contains  a  coloring  matter  belonging  to  the  lipo- 
chromes.  Ochronosis  is  a  browmish  or  brownish-black  pigmentation  of  the  carti- 
lages found  in  rare  cases.    The  nature  of  the  condition  is  unknown. 

Glycogenous  Degeneration. — Glycogen  is  a  carbohydrate,  an  intermediate 
product  in  the  conversion  of  starches  into  sugar.  It  is  found  normally  in  the 
liver,  in  the  mucous  membrane  of  the  uterus,  in  the  voluntary  muscles  and  the 
heart  muscle,  in  leucocytes,  blood  serum,  and  cartilage,  and  in  most  of  the  organs 
during  embryonic  existence.  Glycogen  is  found  in  the  tissues  either  in  solution 
or  as  flakes  or  granules  of  hyaline  appearance,  lying  within  the  cells  or  in  the 
intercellular  substance.  It  is  soluble  in  water.  ^^Qien  treated  with  iodine  it 
stains  a  brownish-red.  Unlike  amyloid,  it  does  not  give  the  reaction  with  iodine 
and  sulphuric  acid.  Amyloid,  again,  is  not  soluble  in  water.  In  examining  tis- 
sues for  the  presence  of  glycogen,  it  is  important  to  fix  and  examine  the  material 
immediately  after  death,  as  the  gl}fcogen  is  quickly  transformed  into  sugar. 

Pathologicallj',  gl}TOgen  is  formed  in  increased  amounts  in  pus  cells,  in  the 
leucocytes  in  certain  cachectic  conditions,  and  in  the  cells  of  some  tumors,  not- 
ably tumors  of  the  kidney  and  suprarenal  (hypernephroma ta),  of  the  cervical 
portion  of  the  uterus,  of  the  testes,  bones,  cartilages,  and  muscles.  In  all  these 
cases  it  is  probably  a  result  of  cell  activity. 

INFILTRATIONS. 

Amyloid,  waxj^  or  lardaceous  mfiltration  is  the  condition  in  which  there  is  a 
deposit  of  a  glassy,  wax-like,  homogeneous  substance  in  the  walls  of  the  smaller 
blood-vessels.  Almost  any  part  of  the  body  may  be  affected.  Amyloid  infiltra- 
tion is  most  commonly  met  with  in  the  spleen,  kidneys,  and  liver;  less  often  in 
the  stomach,  intestines,  heart,  IjTuph  nodes,  suprarenals,  and  pancreas;  rarely 
in  the  muscles,  uterus,  ovaries,  and  respirator}'  tract. 


DISTURBANCES  OF  NUTRITION.  195 

The  exact  nature  of  the  infiltration  is  not  entirely  understood.  It  occurs  as 
a  secondary  disturbance  in  a  variety  of  ailments,  chiefly  chronic  and  infectious, 
which  are  accompanied  by  grave  disturbances  of  nutrition.  Thus  we  get  it  most 
commonly  in  chronic  tuberculosis,  especially  of  the  lungs,  bones,  and  joints;  in 
chronic  suppuration,  as  in  osteomyelitis,  pyemia,  actinomycosis,  glanders;  in 
inveterate  syphilis,  in  chronic  dysentery,  in  prolonged  lactation.  Local  amy- 
loid infiltration  of  the  kidneys  is  occasionally  met  with  in  chronic  Bright's  dis- 
ease. The  condition  is  also  sometimes  found  in  connection  with  leukaemia,  car- 
cinoma, and  severe  malaria.  Ziegler  is  the  authority  for  the  statement  that 
amyloid  change  may  arise  in  the  absence  of  previous  disease.  It  can  be  pro- 
duced experimentally.  Czerny  caused  it  in  dogs  by  inducing  long-continued 
suppuration  with  injections  of  turpentine.  Krawkow  produced  it  in  rabbits  and 
chickens  by  repeated  injections,  in  increasing  quantities,  of  broth  cultures  of  the 
Staphylococcus  pyogenes  aureus  and  the  toxin  of  Bacillus  pyocyaneus.  In 
these  cases  the  condition  appeared  in  from  one  and  a  half  to  two  months. 
Thus  it  is  evident  that  amyloid  change  is  directly  related  to  the  disorder  of 
nutrition  resulting  from  chronic  cachexia.  The  more  intimate  explanation  of 
the  process  is  still  to  seek.  It  has  been  suggested  that  the  parenchjmiatous  cells- 
of  the  various  organs  are  directly  changed  into  amyloid  material,  but  this  is  not 
supported  by  histological  evidence.  Amyloid  is  not  found  within  the  cells,  but 
in  the  interstices  of  connective  tissue  and  in  the  walls  of  blood-vessels.  In  the 
early  stages  it  has  been  found  just  beneath  the  endothelial  lining  of  the  vessels. 
This,  together  with  the  fact  that  the  vessels  are  so  frequently  picked  out  for  the 
transformation,  strongly  supports  the  view,  which  is  now  quite  generally  ac- 
cepted, that  the  amyloid,  or,  more  probably,  some  precursor  of  it,  is  circulating 
in  the  blood  and  is  precipitated  in  the  walls  of  the  vessels  or  in  the  perivascular 
lymphatics.  Possibly  we  should  take  into  accoimt  also  the  selective  properties 
of  the  endothelial  cells,  and  the  influence  of  the  tissue  juices,  which  may  com- 
bine with  the  amyloid  precursors  to  form  amyloid.  We  may  perhaps  here  allude 
to  the  views  of  Von  Recklinghausen  and  Czerny.  The  former  has  advanced  the 
theory  that  the  cells  of  the  organs  excrete  a  homogeneous  substance,  which  co- 
agulates in  the  tissue  spaces  into  the  characteristic  amyloid  deposit.  Czerny 
foimd  cells  giving  the  microchemical  reaction  of  am3doid  in  the  pus  and  blood  of 
animals  which  later  presented  amyloid  change  in  the  spleen.  He  therefore 
thinks  that  in  the  early  stages  the  amyloid  material  is  formed  in  local  foci  of 
suppuration  and  is  carried  to  the  internal  organs  by  the  leucocytes. 

Chemically  speaking,  as  Oddi  and  Krawkow  have  shown,  amyloid  is  a  com- 
pound of  albumin  and  chondroidin-sulphuric  acid.  The  latter  substance  is  found 
normally  in  cartilage  and  all  structures  containing  abundance  of  elastic  tissue, 
especially  in  the  blood-vessels.  Amyloid  does  not  contain  phosphorus.  It  is 
practically  insoluble  in  water,  is  unaffected  to  any  axtent  by  acids  or  alkalies, 
and  resists  the  action  of  the  gastric  juice  and  even  of  decomposition.     There  are 


196  AMERICAN  PRACTICE  OF  SURGERY. 

certain  chemical  tests  which  give  characteristic  reactions  with  amyloid  material. 
To  determine  the  presence  of  amj'loid  in  organs  removed  at  autops}',  thin  slices 
are  taken,  the  blood  is  removed  bj-  washing,  and  the  material  is  allowed  to  re- 
main in  a  solution  of  iodine  in  potassium  iodide  (iodine  1  gm.,  potassium  iodide 
2  gm.,  water  300  c.c.)  for  a  few  minutes.  If  for  any  reason  the  organs  are  alka- 
line, it  is  necessary  to  soak  the  tissue  first  in  acetic  acid.  If  amyloid  be  present, 
a  mahogany-brown,  translucent  coloration  is  produced.  Thin  sections,  stained 
by  this  method,  when  viewed  under  the  microscope,  show  the  amyloid  as  a  glassy, 
transparent  substance  of  a  golden-yellow  color.  More  striking  still  is  the  reac- 
tion produced  with  certain  aniline  dyes.  Microscopic  sections  are  placed  for  two 
or  three  minutes  in  a  somewhat  dilute  waterj-  solution  of  methjd-violet  or  gen- 
tian-violet. The  sections  are  then  washed  in  a  weak  acid  solution,  such  as  acetic 
or  hydrochloric  (two  per  cent),  until  most  of  the  blue  color  is  removed.  If  amj'- 
loid  be  present,  portions  of  the  tissue  will  assume  a  rose-pink  color,  which  can 
also  be  made  out  very  well  under  the  microscope.  The  unaffected  parts  strike  a 
dirty,  grayish-blue  tint. 

Organs  the  seat  of  advanced  amyloid  change  are  usually  enlarged,  their  edges 
somewhat  rounded,  and  are  much  increased  in  consistency,  so  that  they  feel  like 
India  rubber.  On  section  the  amyloid  material  can  often  be  made  out  as  dots  or 
streaks  of  a  grayish,  translucent  appearance,  or  the  surface  of  the  organ  may 
look  as  if  smeared  over  with  gelatin.  Thin  sections  on  being  held  up  to  the  light 
appear  to  be  pale  gray  and  translucent. 

In  the  spleen  amyloid  infiltration  begins  in  the  walls  of  the  arteries,  capil- 
laries, and  smaller  veins,  especially  those  within  the  Malpighian  bodies.  These 
become  greatlj'  enlarged  and  appear  in  the  fresh  state  like  grains  of  half-boiled 
sago;  hence  the  term  "sago  spleen."  Or,  again,  the  condition  may  spread,  in- 
volving the  vessels  and  trabeculse  of  the  pulp,  giving  rise  to  a  diffuse  amyloid  in- 
filtration— "waxy,"  bacony,  or  lardaceous  spleen. 

In  the  kidneys  the  process  begins  in  the  walls  of  the  interlobular  arteries, 
afferent  arterioles,  and  glomerular  capillaries.  The  middle  coats  of  the  arteries 
are  first  and  chiefly  attacked.  The  glomeruli  in  time  become  largely  converted 
into  structureless,  translucent  nodules. 

In  the  liver  it  appears  first  in  the  walls  of  the  intralobular  capillaries,  mainly 
in  the  intermediate  zone  of  the  lobules,  forming  thick,  homogeneous  bands,  be- 
tween which  are  liver  cells  in  all  stages  of  atrophy  and  fatty  degeneration. 

Amyloid  infiltration  is  always  of  serious  import.  It  is  met  with  only  in  most 
dangerous  disorders  and  in  the  most  advanced  stages  of  them.  It  indicates, 
then,  a  bad  prognosis  where  it  can  be  made  out.  It  also  aggravates  the  primary 
disease  by  inducing  atrophy  and  fatty  changes  in  the  cells  with  which  it  comes 
in  contact,  and  causes  marked  circulatory  disturbances,  with  all  their  conse- 
quences, through  alteration  in  the  lumina  of  the  affected  vessels. 

Closely  resembling  amyloid  in  general  appearance,  although  differing  from  it 


DISTURBANCES  OF  NUTRITION.  197 

in  several  important  particulars,  is  hyaline  infiltration.  Like  amyloid,  this  takes 
place  in  the  walls  of  blood-vessels  and  in  the  interstices  of  connective  tissue.  It 
is  also  met  with  in  inflammatory  exudates.  It  is  distinguished  from  amyloid  by 
the  absence  of  the  iodine  reaction  and  the  rose-pink  color  when  treated  with 
aniline  dyes.  By  Van  Gieson's  method  it  stains  a  deep  red,  while  amyloid  stains 
pinkish-yellow  or  brown.  Again,  hyaline  infiltration  is  not  so  regularly  distrib- 
uted in  the  body  as  amyloid,  nor  does  it  have  the  same  etiological  relationship 
with  suppuration  and  chronic  cachexias.  The  close  relationship  which  exists  be- 
tween hyalin  and  amyloid  is  shown  by  the  fact  that  hyaline  deposits  are  not  in- 
frequently found  in  organs  the  seat  of  amyloid  change,  and,  conversely,  amyloid, 
when  introduced  into  the  peritoneal  cavity  of  experimental  animals,  loses  its 
characteristic  staining  properties  and  becomes  like  hyalin. 

Hyaline  infiltration  is  found  in  the  walls  of  sclerotic  vessels,  in  the  heart 
valves  when  the  seat  of  chronic  inflammation,  in  the  connective  tissue  of  the 
thyroid,  ovaries  and  lymph  nodes,  and  in  the  stroma  of  many  tumors.  Hyaline 
transformation  of  the  glomerular  tufts  is  often  met  with  in  the  kidneys  in 
chronic  Bright's  disease.  The  cellulo-fibrinous  exudate  in  certain  cases  of  pleu- 
risy, pericarditis,  and  peritonitis  occasionally  undergoes  this  transformation. 
This  may  lead  to  great  thickening  of  the  serous  membranes,  so  that  they  come 
to  resemble  cartilage  ("icing"  organs,  "Zuckergussorgane").  In  certain  forms 
of  coagulation  of  the  blood,  as,  for  example,  in  the  formation  of  blood-platelet 
thrombi,  the  platelets  become  fused  into  a  mass  resembling  hyalin.  The  so-called 
"hyaline  bodies,"  or  Russell's  "fuchsin  bodies,"  are  homogeneous,  globular 
masses  of  varying  size,  either  single  or  aggregated  in  clusters.  They  are  found 
both  within  and  without  the  cells  in  glandular  proliferations  of  the  gastric  mu- 
cosa and  in  malignant  tumors.  They  strike  a  red  color  with  acid  fuchsin  and 
dark  blue  with  the  Gram-Weigert  stain.  By  some  they  have  been  regarded  as  of 
parasitic  nature.    This,  however,  is  now  believed  to  be  erroneous. 

Certain  changes  in  glia  cells  sometimes  produce  masses  which  stain  black 
with  the  Pal-Weigert  method,  red  with  Van  Gieson's  stain,  and  bright  blue  with 
Weigert's  fibrin  stain,  after  fixation  in  Zenker's  fluid.  Barker  has  shown  that 
the  material  in  question  forms  within  the  glia  cells. 

So-called  amyloid  bodies  or  concretions  are  also  met  with  in  the  prostate  (Fig. 
69),  hypophysis,  central  nervous  system,  and  lungs.  Some  are  homogeneous  and 
others  laminated.  In  the  latter  case  it  is  not  uncommon  to  find  in  the  centre  of 
the  concretions  cell  debris,  indicating  that  in  some  cases  at  least  the  process  is 
probably  a  degenerative  one,  resulting  from  the  cutting  off  of  desquamated  cells 
from  their  nutritive  supply.  Occasionally,  but  by  no  means  invariably,  such 
bodies  give  the  reaction  for  amyloid.  Their  exact  relationship  to  amyloid,  hya- 
lin, or  colloid  cannot  as  yet  be  stated. 

The  exact  nature  of  the  hyaline  change  is  still  unknown.  A\nien  occm-ring  in 
the  connective  tissue  of  certain  organs,  especially  that  of  the  conjunctiva,  and  in 


198  AMERICAN  PRACTICE  OF  SURGERY. 

inflammatory  exudates,  hyaline  material  appears  to  be  more  of  a  degeneration 
than  an  infiltration.  Theoretically,  the  connective-tissue  elements  may  be  trans- 
formed into  hyaline  material  containing  no  nuclei,  or  the  hyalin  may  be  a  secre- 
tion from  the  connective-tissue  cells.  In  some  cases  the  process  appears  to  be 
both  a  degeneration  and  a  deposit,  the  interstices  of  the  connective  tissue  being 
first  filled  with  a  clear,  homogeneou?  material,  into  which  the  cells  gradually 
fuse. 

Calcification  and  Analogous  Conditions. — Under  certain  conditions  there  may 
be  a  deposit  in  the  body  of  crystalline,  amorphous,  or  granular  salts,  derivatives 
of  lime  or  uric  acid.  This  is  called  petrifying  infiltration.  The  deposition  of  lime 
salts  is  usually  termed  calcareous  infiltration  or  calcification.  This  is  of  not  in- 
frequent occurrence.  The  precipitation  of  these  substances  may  take  place  into 
tissues  or  structures  which  are  normally  part  of  the  hoiXj,  into  structures  which 


Fig.  69. — Corpora  (^mvlaiea  m  the  Prostate  {LcUz  obj  No.  3.)  (From  the  author's  private 
collection.) 

are  separated  from  their  normal  relationships,  or  into  foreign  bodies  imported 
from  without.  In  the  last  two  instances  we  speak  of  the  formation  of  concre- 
tions or  calndi. 

Calcification  occurs  as  a  normal  change  in  the  formation  of  bone  from  carti- 
lage. In  advanced  life  lime  salts  are  deposited  with  great  regularity  in  the  costal 
cartilages,  in  the  cartilages  of  the  larynx,  and  in  the  walls  of  the  arteries.  It  is 
generally  believed  that  this  is  due  to  certain  involutionary  changes  in  the  bone 
which  occur  in  old  age,  the  lime  salts  being  reabsorbed  and  deposited  elsewhere 
in  the  body.    In  some  cases  of  osteoporosis  and  osteomalacia  the  .salts  are  depos- 


DISTURBANCES  OF  NUTRITION.  199 

ited  in  apparently  normal  tissue,  as  in  the  lungs,  kidnej's,  and  gastric  mucosa. 
This  process  is  sometimes  referred  to  as  metastatic  calcification  or  lime  metastasis. 

Calcification  almost  never  occurs  in  normal  tissues.  It  is  practically  alwa3's 
preceded  by  cloudy  swelling,  fatty  degeneration,  hyaline  transformation,  casea- 
tion, or  necrosis.  Calcareous  deposit  occurs  not  infrequently  in  connective  tis- 
sue which  has  become  sclerosed  or  h3-aline;  for  example,  in  arteriosclerosis,  in 
the  heart  valves  when  the  seat  of  chronic  endocarditis,  in  chronic  pleurisy,  em- 
pyema, and  chronic  pericarditis,  and  in  the  thyroid  gland.  It  occurs  in  tumors, 
such  as  uterine  fibroids.  It  is  found  in  necrobiotic  and  necrotic  areas,  as  in  case- 
ation or  coagulation  necrosis,  in  old  inflammatory  exudates,  in  thrombi,  and  in 
the  capsules  of  animal  parasites.  Calcareous  infiltration  may  also  take  place  in 
dead  ganglion  cells  of  the  brain  in  cases  of  shock  and  softening.  It  is  met  with 
in  the  renal  epithelium  in  the  necrosis  resulting  from  ansemia  and  from  in- 
toxications, such  as  those  due  to  corrosive  sublimate,  aloin,  and  bismuth.  For- 
eign bodies,  such  as  a  dead  foetus  (lithopcedion),  catheters,  bullets,  pessaries,  etc., 
may  become  incrusted  with  lime  salts. 

The  exact  chemical  reactions  which  occur  in  the  formation  of  lime  deposits 
are  still  more  or  less  a  matter  of  debate.  The  lime  is  present  in  the  tissues  in  the 
form  of  carbonate  and  phosphate.  "\^^ien  strong  mineral  acids  are  added  to  the 
material,  there  is  an  evolution  of  carbonic  dioxide.  The  problem  is  chiefly  indi- 
cated in  the  following  questions :  How  do  the  lime  salts  enter  the  system?  In 
what  form  do  they  exist?    What  brings  about  their  preciijltation? 

The  physiological  infiltration  of  certain  tissues  with  lime  salts  which  occurs 
in  old  age  is  with  great  probability  to  be  referred,  at  least  in  the  main,  to  a 
transference  of  the  lime  from  the  bones  to  other  parts.  The  fact,  howe^'er,  that 
we  find  calcification  so  often  in  early  life  would  indicate  that  there  must  be  an- 
other explanation  for  its  occurrence.  We  have  to  believe,  then,  that  the  process 
is  intimately  bound  up  with  the  body  metabolism  and  that  the  ultimate  source 
of  the  lime  is  in  the  food.  A  farther  point  is  that  calcification  does  not  occur 
except  in  tissues  that  are  in  a  more  or  less  advanced  stage  of  degeneration. 
There  appears  to  be  in  such  tissues  some  chemical  substance  which  determines 
the  place  of  the  deposit.  In  rabbits  and  ruminants,  whose  food  abounds  in 
lime  salts,  it  is  a  very  common  thing  to  find  lime  deposits  at  points  where  there 
is  local  death  of  tissue.  Inasmuch,  however,  as  such  local  death  occurs  fre- 
quently in  human  beings  without  calcification  supervening,  we  have  to  conclude 
that  an  excess  of  lime  salts  in  the  food  is  necessary.  These  salts,  no  doubt,  are 
carried  throughout  the  body  in  the  blood  and  lymph,  presumaljly  in  a  soluble 
form.  "V^lien  they  reach  the  degenerated  tissues  it  is  held  by  some  that  they  are 
acted  upon  by  the  phosphoric  acid  and  nascent  carbonic  dioxide  and  thrown 
down  in  an  insoluble  form,  or,  what  is  perhaps  more  likely,  they  first  combine 
with  the  fats  in  the  part  to  form  soaps,  which  are  in  their  turn  decomposed. 
The  salts  are  thus  laid  down  in  solid  masses  both  within  the  specific  cells  of  the 


200  AMERIC\\X  PRACTICE  OF  SURGERY. 

tissue  and  in  the  intercellular  substance,  and  may  abound  to  such  a  degree  as  to 
render  the  part  hard  like  stone.  Microscopically,  the  lime  appears  as  fine,  refrac- 
tile  granules,  which  are  dark  and  somewhat  opaque  by  transmitted  light  and 
white  by  reflected  light.  In  sections  stained  by  hsematoxylin  the  granules  strike 
a  pm-plish-black  color.  The  condition  is  essentially  one  of  deposition  of  mineral 
matter,  and  hence  is  often  termed  petrifaction,  as  contradistinguished  from  ossi- 
fication, in  which,  together  with  the  deposition  of  salts,  there  is  a  formation  of 
new  tissue. 

The  deposition  of  salts  of  uric  acid  is  of  great  practical  importance.  In  the 
disease  known  as  gout  thej^  are  laid  down  in  the  articular  cartilages,  ligaments, 
tendons,  and  tendon  sheaths,  the  subcutaneous  connective  tissue,  and  in  the 
kidneys.  The  material  is  deposited  in  the  form  of  needle-shaped  crystals,  some- 
times trimcated,  in  the  intercellular  substance  of  the  cartilage.  At  first  the  car- 
tilage cells  do  not  suffer,  but  later  the  deposit  may  be  so  great  that  the  cartilage 
becomes  opaque,  looking  like  chalk  by  reflected  light.  In  the  most  extreme 
cases  the  affected  part  may  actually  necrose.  As  might  be  expected,  the  pres- 
ence of  so  much  foreign  material,  and  that  of  an  irritating  kind,  leads  to  inflam- 
mation of  the  structures  involved.  In  gout  there  is  evidently  a  marked  disturb- 
ance of  metabolism,  in  which  unusually  large  quantities  of  uric  acid  are  formed 
in  the  blood.  Uric  acid  is  a  very  insoluble  substance,  and  it  has  been  suggested 
by  Roberts  that  it  exists  in  the  blood  as  a  quadriurate  soluble  in  water.  This 
is  broken  up  in  part  into  sodium  biurate,  which  is  the  substance  precipitated. 

The  uric-acid  infarcts  found  in  new-born  infants  deserve  a  word.  They  are 
observed  usually  in  the  first  two  weeks  of  life,  rarely  in  the  foetus,  and  appear  as 
yellowish-  or  reddish-white  striated  marks  in  the  papillae.  They  are  due  to  the 
deposition  of  urates  in  the  uriniferous  tubules,  and  probably  indicate  a  slight 
disturbance  of  metabolism. 

Calculi  or  concretions  are  rounded,  nodular,  or  branched  masses  of  mineral 
matter  formed  in  the  tissue  spaces,  in  the  lumina  of  vessels,  in  ducts  of  glands, 
and  in  cavities  lined  by  mucous  membrane,  by  precipitation  from  the  fluids  or 
excretions  of  the  body.  Some  of  the  so-called  "free  bodies"  are  composed  en- 
tirely of  organic  material,  such  as  certain  of  the  "amyloid"  concretions  in  the 
prostate  and  central  nervous  sj^stem,  but  as  a  rule  in  the  organic  matrix  there  is 
a  deposit  of  insoluble  salts. 

Brain  sand  is  composed  of  small  calcareous  masses  of  this  kind,  and  is  found 
normally  in  the  pineal  gland,  in  certaui  tmnors  of  the  dura  and  pia  mater, 
and  of  the  choroid  plexus,  hence  called  psammomata.  Similar  concretions  are 
at  times  foimd  in  the  various  cavities  of  the  body.  Such  are  the  petrifications  of 
old  thrombi  (arterioliths,  phleboliths),  calculi  in  the  hepatic  and  urinary  pas- 
sages, concretions  in  the  pancreatic  and  salivary  ducts,  in  the  nasal  (rhinolitlis) 
and  respiratory  passages  (broncholiths),  in  the  external  auditory  meatus  (oto- 
liths), fecal  accumulations  in  the  intestines,  preputial  stones. 


DISTURBANCES  OF  NUTRITION.  201 

Gall  stones  are  among  the  commonest  forms  of  calculi.  They  are  met  with 
usually  after  middle  life,  and  are  much  more,  frequent  in  women  than  in  men 
(2  to  4: 1).  According  to  their  chemical  constitution  we  may  recognize  four  kinds 
of  biliary  calculi — cholesterin,  bilirubin-calcium,  pigmentary,  and  calcium  car- 
bonate. Various  combinations  of  these  may  occur.  Pure  cholesterin  calculi  are 
rare.  They  are  often  solitary  and  may  form  a  complete  cast  of  the  gall  bladder. 
They  are  light-colored,  often  somewhat  greenish,  are  hard,  and  break  with  a 
crystalline  fracture.  They  are  made  up  of  radial  and  concentric  laminae.  Mixed 
calculi  of  bilirubin  or  biliverdin  and  calcium  salts  are  more  common.  They  vary 
greatly  in  size,  are  often  very  numerous  and  faceted,  are  hard,  and  of  a  dark 
brownish  color.    Pigment  calculi  are  small,  irregular,  and  friable. 

The  modus  operandi  in  the  formation  of  gall  stones  has  been  fairly  well  worked 
out  by  Naunyn  and  others.  The  first  requisite  for  the  formation,  of  biliary  cal- 
culi is  an  albuminous  matrix,  and  then  an  abnormal  biliary  secretion.  Catarrh 
of  the  biliary  passages  provides  the  first  condition.  This  may  be  brought  about 
by  stasis  of  the  bile,  such  as  may  be  induced  by  sedentary  habits,  obesity,  tight 
lacing,  and  too  long  intervals  between  meals.  This  leads  to  slight  irritation  of 
the  mucosa  with  the  liberation  of  an  albuminous  secretion  and  the  desquama- 
tion of  some  of  the  lining  cells.  Or  the  same  result  may  be  brought  about  by  in- 
testinal or  general  systemic  disturbances,  resulting  in  invasion  of  the  biliary  pas- 
sages by  bacteria.  The  Bacillus  coli,  the  Bacillus  typhosus,  the  staphylococcus, 
and  the  streptococcus  have  been  found  in  the  bile  passages,  and  are  known  to 
persist  there  on  occasion  for  months.  Both  the  colon  and  the  typhoid  bacillus 
have  been  found  in  gall  stones,  and  typhoid  fever  is  now  looked  upon  as  an  im- 
portant etiological  factor.  Biliary  calculi  have  also  been  produced  experimen- 
tally by  injecting  bacteria  into  the  gall  bladders  of  animals.  The  desquamated 
cells  and  albumin  tend  to  fuse  together  and  form  the  nucleus  in  and  about  which 
the  various  salts  will  be  deposited.  The  source  of  the  cholesterin  and  bilirubin- 
calcium  is  not  entirely  clear,  and  conflicting  opinions  have  been  expressed. 
Probably  Naunyn's  view  is  most  widely  held.  According  to  this,  cholesterin  is 
formed  in  situ,  being  produced  by  the  diseased  mucous  membrane.  Increased 
acidity  of  the  bile  appears  to  have  something  to  do  with  it.  Bilirubin-calcium 
is  not  a  normal  constituent  of  the  bile.  Bile  salts  seemingly  have  a  retarding 
influence  on  the  formation  of  bilirubin-calcium,  but  this  inhibitory  power  is 
counteracted  by  the  presence  of  albumin,  so  that  the  precipitation  of  this  sub- 
stance is  similarly  traceable  to  the  condition  of  inflammation.  The  deposition 
appears  to  take  place,  not  according  to  the  usual  rules  of  crystallization,  but 
under  the  influence  of  the  albumin  the  mineral  matter  is  precipitated  in  the 
form  of  plates.  Owing  apparently  to  variations  in  the  local  condition  of  things, 
the  calculus  is  built  up  gradually  layer  after  layer,  and  in  radial  form.  The 
great  variation  in  the  composition  of  gall  stones  would,  however,  seem  to  in- 
dicate that  there  are  other  factors  besides  those  mentioned.    Probably  local 


202  AMERICAN  PRACTICE  OF  SURGERY. 

disturbance  of  the  hepatic  functions  and  disorders  of  systemic  metabolism  are 
of  importance. 

Urinary  Calculi. — Tl^ese  calcuh  may  be  found  within  the  tubules  of  the  kid- 
ney, in  the  kidney  pelvis,  and  in  ureter,  bladder,  and  urethra.  Not  infrequently 
they  are  formed  in  one  place  and  carried  by  the  flushing-out  action  of  the  urine 
and  muscular  activity  to  some  more  remote  part.  Calculi  are  produced  in  the 
kidney  (renal  calculi)  or  in  the  bladder  (vesical  calculi).  By  their  presence  they 
frequently  cause  obstruction  to  the  outflow  of  the  urine  and  inflammatory  dis- 
turbances, with  even  destruction,  of  the  urinary  organs. 

The  chemical  constitution  of  urinary  calculi  depends,  on  the  one  hand,  on 
the  composition  of  the  urine,  which  in  its  turn  is  dependent  on  the  general  meta- 
bolic processes  of  the  body;  and,  on  the  other,  on  certain  chemical  changes  oc- 
curring in  the  urine  after  its  secretion  by  the  kidneys.  As  in  the  case  of  biliary 
calculi,  we  have  to  recognize  both  local  and  general  disorders  of  metabolism. 
Chemically  speaking,  urinary  calculi  may  be  divided  into  the  following  forms: 
(1)  The  uratic;  (2)  the  phosphatic;  (3)  the  calcium  carbonate;  (4)  the  calcium 
oxalate;  (5)  cystin;.  (6)  xanthin. 

Calculi  are  built  up  gradually,  and,  owing  to  variations  in  the  conditions, 
may  present  a  different  composition  in  different  parts,  or  several  calculi  of  dif- 
ferent composition  may  be  found  in  the  same  patient. 

The  important  element  in  the  production  of  urinary  calculi  is  the  disturbance 
of  the  general  metabolism.  This  cannot  act,  however,  unless  the  local  conditions 
are  favorable.  As  we  have  seen  in  the  case  of  biliary  concretions,  an  albuminous 
medium  is  a  necessity.  The  work  of  Ebstein,  Posner,  Naunyn,  and  Studensky, 
among  others,  has  shown  conclusively  that  albuminous  fluids  have  the  power  of 
determining  the  precipitating  of  the  crystalline  salts  from  their  solutions,  much 
in  the  same  way  as  in  the  formation  of  the  hen's  egg,  where  the  albumin  has  the 
power  of  separating  out  carbonate  of  lime  from  solutions  of  calcium  salts.  To 
bring  about  the  excretion  of  albuminous  material,  the  chief  factor  is  of  course 
inflammation.  This  may  be  produced  by  stagnation  of  urine,  alterations  in  the 
composition  of  the  urine,  local  bacterial  invasion,  fermentative  processes,  and 
the  like.  The  lining  cells  desquamate  to  some  extent  and  act  as  a  sort  of  nucleus. 
As  in  the  case  of  biliary  calculi,  catarrhal  inflammation  is  of  great  importance; 
but  as  every  catarrh  does  not  result  in  calculus  formation,  we  must  believe  that 
other  factors  are  at  work.  These  are  not  altogether  clear,  but  are  probably  to 
be  looked  for  in  some  abnormality  of  general  metabolism.  Hyperacidity  of  the 
urine,  due  to  an  excess  of  uric  acid,  is  a  predisposing  cause  of  the  precipitation 
of  lU'atic  salts  and  oxalates.  When  urine  becomes  alkaline,  as  from  retention 
and  the  activity  of  certain  bacteria,  ammonio-magnesium  phosphate  is  formed 
and  may  be  thrown  down.  Incrustations  of  phosphates  occasionally  are  formed 
upon  foreign  substances  which  get  into  the  bladder,  such  as  bits  of  catheters, 
slate  pencils,  hairpins,  tooth  brushes,  etc. 


DISTURBANCES  OF  NUTRITION.  203 

Cystin  calculi  originate  in  disturbances  which  take  place  outside  of  the  uri- 
nary organs.  Such  calculi,  which  are  rare,  are  due  to  abnormal  decomposition 
of  albuminous  substances  in  the  intestines  brought  about  by  bacteria.  Cystin 
calculi  are  yellowish,  soft,  and  waxy. 

Xanthin  calculi  are  also  rare.  They  are  found  in  the  bladder,  and  are  reddish 
in  color,  soft,  and  friable. 

In  cattle,  calculi  formed  of  silicates  may  be  met  with. 

Fecal  calculi  are  composed  of  inspissated  fecal  matter  infiltrated  and  in- 
crusted  with  lime  salts.  Constipation  and  the  presence  of  intestinal  diverticula 
favor  their  formation. 

Salivary  and  pancreatic  calculi  are  also  composed  of  lime  salts,  usually  the 
carbonate. 

Glycogenous  Infiltration. — Infiltration  with  glycogen  is  found  especially  in  the 
case  of  diabetes  mellitus.  In  this  disease  both  glycogen  and  sugar  are  produced 
in  greatly  increased  amounts.  The  glycogen  may  be  demonstrated  in  the  leuco- 
cytes, blood  plasma,  liver,  and  kidneys.  In  the  last-mentioned  organs  the  de- 
posit occurs  chiefly  in  the  epithelial  cells  lining  the  loops  of  Henle.  It  is  usually 
found  in  hyaline-looking  droplets  near  the  nuclei,  and  may  be  recognized  by  the 
before-mentioned  tests.  Experimental  diabetes,  produced  by  the  removal  of  the 
pancreas,  is  followed  similarly  by  a  deposit  of  glycogen  in  the  leucocytes,  liver, 
and  kidneys. 

Pigmentary  Infiltration. — We  have  above  referred  to  a  form  of  pigmentation 
which  is  due  to  metabolic  changes  in  the  cells  themselves.  This  has  properly 
been  regarded  as  a  true  degeneration.  There  are  other  forms  of  pigmentation, 
however,  which,  while  in  some  instances  the  result  of  disturbed  metabolism,  are, 
so  far  as  the  affected  cells  and  tissues  are  concerned,  the  result  of  causes  op- 
erating outside  of  them.  Here  the  pigment  which  is  produced  in  one  part  of 
the  body  is  carried  by  the  blood  or  lymph  to  other  regions,  where  it  is  deposited 
as  so  much  foreign  material.  This  is  pigmentary  infiltration.  In  this  class  are 
to  be  considered  the  pigmentation  which  results  from  breaking  down  of  the  red 
blood  corpuscles — hcematogenous  pigmentation,  and  that  due  to  the  accumulation 
of  bile  in  the  tissues — biliary  pigmentatio7i. 

In  the  first-mentioned  variety  the  pigmentation  is  due  to  the  deposition  in 
the  tissues  of  coloring  matter  derived  from  haemoglobin.  This  may  occur  as  the 
result  of  hemorrhages  or  thrombosis,  where  the  blood  cells  become,  as  it  were, 
extravascular,  and  midergo  retrograde  changes,  or  it  is  due  to  the  solution  of 
the  haemoglobin  in  the  plasma  and  the  formation  of  granules  of  pigment  in 
the  blood. 

Hematogenous  pigments  occur  in  two  main  forms — hamatoidin  and  hcemo- 
siderin.  Hsematoidin  is  found  in  the  form  of  yellowish  or  brownish  granules,  or 
as  reddish  rhombic  or  acicular  crystals.  It  responds  to  Gmelin's  test  and  is  be- 
lieved to  be  practically  if  not  quite  identical  with  bilirubin.    It  does  not  contain 


204  AMERIC.\N  PRACTICE  OF  SURGERY. 

iron,  is  insoluble  in  water,  ether,  and  alcohol,  but  soluble  in  alkalies  and  chloro- 
form. It  is  found  more  particularly  in  connection  with  large  hemorrhages,  espe- 
cially when  they  occur  into  some  cavity.  In  such  cases  the  blood  corpuscles  are 
to  a  comparatively  slight  extent  acted  upon  by  living  cells  and  the  supply  of 
oxygen  is  relatively  scanty. 

Hsemosiderin  occurs  in  yellowish-brown  or  brown  granules,  usually  within 
the  cells,  but  also  free  in  the  tissue  spaces.  It  is  insoluble  in  water,  and  differs 
from  hfematoidin  in  that  it  contains  iron.  This  may  be  demonstrated  by  Perl's 
test.  If  a  microscopic  section  containing  this  pigment  be  treated  with  a  three- 
per-cent  solution  of  potassiimi  ferrocyanide  and  then  with  a  weak  solution  of 
hydrochloric  acid,  tlie  iron-containing  granules  take  on  a  bright  blue  color,  owing 
to  the  formation  of  Prussian  blue.  If  treated  with  hydrogen  sulphide,  the  gran- 
ules turn  black.  Hsemosiderin  is  formed  where  the  blood  cells  are  exposed  in 
small  quantities' to  the  action  of  living  cells  and  oxygen.  Therefore  we  find  it  at 
the  site  of  small  effusions  of  blood,  at  the  margins  of  larger  ones,  in  small  thrombi, 
and  in  organs  the  seat  of  chronic  passive  congestion. 

Hsematogenous  pigmentation  arises,  in  general,  wherever  there  is  extravasa- 
tion of  blood.  The  pigmentation  is  to  be  attributed  to  phj^sical  and  chemical 
changes  in  the  red  corpuscles  when  out  of  their  normal  environment,  resulting 
in  a  transformation  of  the  haemoglobin.  The  extravasation  of  the  blood  may  be 
due  to  injury,  thrombosis,  rupture  of  vessels,  or  degenerative  changes  in  the 
vessel  walls,  the  result  of  the  deleterious  action  of  mineral,  bacterial,  or  other 
toxins.  After  an  extravasation  of  blood  the  red  cells  are  to  some  extent  broken 
down,  and  there  is  an  attempt  on  the  part  of  the  cells  of  the  body  to  remove  the 
debris.  The  process  appears  to  be  as  follows :  Some  of  the  imaltered  red  corpus- 
cles get  back  to  the  circulation  by  means  of  the  hmiphatics;  some  fragment  and 
disintegrate  into  brownish  or  reddish  particles,  containing  haemoglobin;  some, 
again,  lose  their  haemoglobin,  which  dissolves  out  in  the  plasma,  and  the  albu- 
minous framework  of  the  cells  ultimately'  breaks  down.  Part  of  the  liberated 
haemoglobin  passes  in  the  circulation  to  the  organs  of  excretion,  and  is  eliminated 
in  the  urine  as  methsemoglobin  and  urobilin.  The  remainder,  together  with  the 
remains  of  the  red  corpuscles  and  other  detritus,  is  picked  up  by  the  phagocytes 
or  carried  by  the  l}Tnph  to  various  organs,  such  as  the  regional  lymph  nodes, 
spleen,  liver,  and  bone-marrow,  where  it  is  acted  upon  by  the  cells  of  the  part  or 
by  the  oxygen,  and  deposited  in  the  form  of  3'ellowish  or  brownish  granules. 
The  color  changes  from  black  to  brown,  greenish-yellow,  and  yellow,  as  maj^  be 
observed  in  the  familiar  instance  of  the  common  "black  eye."  Here  the 
changes  m  color  furnish  an  external  indication  of  the  chemical  transformation 
which  occurs  in  all  such  cases.  Ultimately,  the  haemoglobin  is  transformed  into 
haematoidin,  haemosiderin,  or  both. 

Similar  pigmentation  occurs  from  the  destruction  of  the  red  corpuscles  in  the 
circulating  blood.    This  is  met  with  in  such  conditions  as  septic  infection,  per- 


DISTURBANCES  OF  NUTRITION.  205 

nicious  ansemia,  leuksemia,  and  malaria,  in  poisoning  with  certain  substances, 
like  potassium  chlorate,  antipyrin,  toluylenediamin,  fungi,  and  some  bacterial 
toxins ;  and  after  the  introduction,  into  the  circulation  of  one  animal,  of  the  blood 
of  another  of  a  different  species.  In  such  cases  the  hemoglobin  may  be  lib- 
erated into  the  plasma  (hcEmoglohinceinia)  and  excreted  by  the  urine,  which  thus 
becomes  brownish-red  or  dark  red  in  color  (hcemoglohinuria,  inethcemoglo- 
binuria). 

Up  to  a  certain  point  the  organs  of  the  body  directly  concerned  in  the  trans- 
formation are  able  to  deal  with  the  increased  amount  of  hsemoglobin  and  its  de- 
rivatives which  reaches  them,  but  in  some  cases  so  much  pigment  is  liberated 
that  the  blood-destroying  organs  become  highly  colored,  or  even  the  whole  body 
may  become  affected.  This  is  the  case  in  a  curious  and  rare  affection,  called  by 
Von  Recklinghausen  hoemochromatosis,  in  which  hEemosiderin  is  deposited  in  all 
the  organs  and  tissues  of  the  body.  We  have  met  with  one  case  of  this,  in  which 
the  skin  and  mucous  membranes  were  of  a  dark  leaden  hue.  The  condition  is 
associated  with  fibroid  changes  in  the  liver  (cirrhosis),  pancreas  (diabete  bronze), 
or  in  both.  The  liver  is  able  to  change  part  of  the  pigment  which  reaches  it  into 
bilirubin,  and  excretes  it  in  the  bile,  but  any  excess  in  the  amount  which  it  is 
able  to  transform  is  deposited  in  the  various  tissues,  and  gradually  eliminated 
by  the  kidneys  as  urobilin. 

In  the  liver  hajmatoidin  is  usually  deposited  in  the  parenchymatous  cells 
toward  the  centre  of  the  lobules,  while  hemosiderin  is  laid  down  more  at  the 
periphery.  In  extensive  hsemosiderosis  the  iron-containing  pigment  is  laid  down 
in  the  interstices  of  the  connective  tissue  of  the  portal  sheaths  as  well.  In  the 
spleen,  lymph  nodes,  and  bone-marrow  the  pigment  is  chiefly  found  in  the  endo- 
thelial cells  lining  the  blood-vessels.  In  the  kidneys  it  is  to  be  found  in  the  se- 
creting cells  lining  the  convoluted  tubules,  in  the  endothelium  of  the  vessels,  and 
in  the  lumina  of  the  tubules. 

In  another  class  of  cases  the  pigment  is  produced  in  some  other  part  of  the 
body  by  disturbed  metabolism,  and  is  then  carried  by  the  lymph  stream  or  by 
leucocytes  to  the  pigmented  part.  An  example  of  this  is  the  transferrence  of 
melanin  from  a  necrosing  melanotic  sarcoma  to  the  spleen,  lymph  nodes,  and 
kidneys.  The  pigment  may  appear  in  the  urine,  and  casts  of  melanin  are  some- 
times to  be  found  in  the  kidney  tubules. 

The  second  main  form  of  pigmentary  deposit  is  the  biliary.  In  certain  cases 
of  obstruction  to  the  free  excretion  of  bile,  it  enters  the  blood  and  lymph  and 
leads  to  a  yellowish  or  sometimes  greenish  discoloration  of  the  whole  body.  The 
pigments  of  bile  are  produced  in  the  liver  and  are  derived  from  the  haemoglobin 
of  the  blood,  hsematoidin  and  bilirubin  being  identical  chemically.  Under  nor- 
mal conditions  the  bilirubin  formed  in  the  liver  is  passed  out  in  the  bile  into  the 
intestine,  where,  after  effecting  certain  changes  in  the  food  stuffs,  it  is  in  part 
evacuated  with  the  faeces.    Part  of  it,  however,  is  absorbed  through  the  intes- 


206  AMERICAN  PRACTICE  OF  SURGERY. 

tinal  mucosa  into  the  blood.  Here  it  undergoes  some  transformation,  the  exact 
nature  of  which  is  quite  unknown,  Ijut  eventually  it  appears  in  the  urine  in  the 
form  of  urobilin. 

Any  condition  which  interferes  with  the  free  discharge  of  the  bile  from  the 
liver  and  bile  passages  will  give  rise  to  jaundice  or  icterus.  Such  causes  may  be 
at  work  in  connection  with  the  larger  bile  passages  or  within  the  liver  itself.  In 
cases  of  jaundice  not  only  are  all  the  structures  of  the  body  stained  with  bile, 
but  the  bile  passes  out  in  the  urine,  in  severe  cases  causing  it  to  assume  a  dark 
brownish  color.  Obstruction  of  the  bile-ducts  may  be  due  to  catarrhal  inflam- 
mation of  the  mucous  membrane,  impacted  calculi,  the  pressure  of  adhesions, 
scars  or  tumors,  abscesses,  enlarged  lymph  nodes,  cirrhosis  of  the  liver,  and 
tumors  within  the  liver.  In  some  few  cases,  as  in  acute  yellow  atrophy  of  the 
liver,  some  toxin,  apparently  of  an  infectious  nature,  seems  to  be  at  work,  with- 
out gross  evidences  of  obstruction  to  the  outflow  of  bile. 

When  the  obstruction  is  complete  no  bile  reaches  the  intestines.  Consequently, 
the  faeces  become  pale  and  clay-colored  and  very  foul  from  abnormal  fermenta- 
tion. Intestinal  digestion  is,  of  course,  interfered  with.  In  bad  cases  delirium, 
convulsions,  coma,  and  all  the  features  of  a  profound  toxgemia  may  supervene.  . 

The  obstruction  to  the  discharge  of  the  bile  leads  to  dilatation  of  all  the  bile- 
ducts  and  of  the  finer  bile  capillaries  within  the  liver  itself.  These  latter  may 
rupture  and  the  bile  may  enter  the  blood  directly.  Ordinarily,  however,  it  passes 
into  the  lymph  channels  and  gets  into  the  circulation  by  way  of  the  thoracic 
duct.  The  liver  cells  become  pigmented,  owing  to  the  impossibility  of  their 
getting  rid  of  their  secretion.  All  the  organs  and  tissues  of  the  body  assume  a 
yellowish  or  greenish  tinge,  and  under  the  microscope  solid  masses  of  brownish 
or  yellowish  pigment  in  granular  form  can  be  recognized,  especially  in  the  lymph 
nodes,  spleen,  and  bone-marrow.  In  the  more  persistent  and  severe  forms  of 
jaundice  the  various  organs  may  contain  bilirubin  in  solid  form,  or,  rarely,  in 
rhombic  or  acicular  crystals.  It  should  be  remarked  also  that  the  presence  of 
biliary  acids  in  the  blood  leads  to  breaking  down  of  the  corpuscles  and  liberation 
of  the  haemoglobin.  This  increases  the  work  of  the  liver  and  provides  more  ma- 
terial to  be  converted  into  bilirubin.    Thus  a  vicious  circle  is  the  result. 

Besides  the  obstructive  form  of  jaundice  just  described,  there  is  another  very 
important  type,  due  to  the  destruction  of  the  red  blood  corpuscles  in  the  circulat- 
ing blood.  This  may  be  the  result  of  a  variety  of  causes,  the  most  notable  being 
the  infections  and  intoxications.  Among  these  are  septicaemia,  yellow  fever,  in- 
halation of  ether  and  chloroform,  snake  bite,  transfusion  of  blood,  and  the  exhibi- 
tion of  toluylenediamin.  This  form  of  jaundice  was  formerly  termed  hcematogen- 
ous,  under  the  impression  that  the  bilirubin  was  produced  in  the  blood.  We  know 
now,  however,  from  the  experiments  of  Naunyn  and  Minkowski,  that  the  liver 
is  essential  to  the  production  of  bilirubin,  so  that  the  more  correct  nomenclature 
would  be  limmo-hcpatogenous  jaundice.    In  such  cases  there  must  be  an  increased 


DISTURBANCES  OF  NUTRITION.  207 

formation  of  bilirubin  in  the  liver,  and  this  material  then  makes  its  way  into  the 
general  circulation.  How  this  occurs  is  not  certainly  known,  but  some  think 
that  the  main  factor  is  a  catarrhal  inflammation  of  the  smaller  bile  ducts  and 
capillaries  in  the  liver. 

Allied  to  jaimdice  is  the  sallow,  earthy  tint  of  the  skin  found  in  cases  of  con- 
stipation and  cachexia.  Here,  there  may  be  an  absorption  of  urobilin  from  the 
intestine  into  the  blood,  and  a  moderate  grade  of  disintegration  of  the  red  cor- 
puscles due  to  toxaemia. 

Deposition  of  Foreign  Substances. — Foreign  material  may  enter  the  body 
from  the  external  world  and  be  deposited  in  the  tissues.  Such  substances  may 
reach  the  interior  of  the  body  in  three  ways — by  the  skin,  by  the  alimentary 
tract,  and  by  the  lungs. 

Perhaps  the  commonest  foreign  substances  introduced  through  the  skin  are 
Indian  ink  and  certain  aniline  colors  employed  in  the  process  of  tattooing.  Some 
of  the  introduced  pigment  in  these  cases  remains  in  the  minute  scars  that  form, 
while  some  is  carried  away  and  deposited  in  the  nearest  lymph  nodes,  which  in 
their  turn  become  pigmented.  Explosions  may  drive  particles  of  gunpowder, 
coal  dust,  or  dirt  into  the  skin. 

The  chief  substances  that  enter  the  system  through  the  alimentary  tract  are 
lead,  arsenic,  copper,  and  silver.  The  prolonged  exhibition  of  arsenic  leads  to  a 
brownish  discoloration  of  the  skin.  In  chronic  lead-poisoning  the  lead  is  depos- 
ited in  the  form  of  a  sulphide  along  the  margin  of  the  gums.  Copper  leads  to  a 
greenish  pigmentation  of  the  gums.  In  former  days  salts  of  silver  were  exten- 
sively used  in  medical  practice,  especially  for  certain  nervous  affections.  After 
the  prolonged  use  of  silver,  the  metal,  presumably  in  the  form  of  an  albuminate, 
is  deposited  in  the  form  of  brownish  or  blackish  granules  in  the  tissues,  which 
assume  a  dark  leaden  gray  color  (argyria).  The  silver  is  laid  down  principally 
in  the  skin,  in  the  kidneys,  in  the  intima  of  the  vessels,  in  the  serous  membranes, 
and  in  the  choroid  plexus  of  the  brain. 

The  inhalation  of  foreign  material  leads  to  a  deposit  of  the  inspired  substance 
in  the  hmgs  (pneumonokoniosis) .  The  most  usual  pigment  thus  laid  down  is 
coal  dust  (anthracosis) ;  next  to  that,  particles  of  stone  {chalicosis,  silicosis) ;  and 
next,  iron  (siderosis).  A  variety  of  other  substances  may  on  occasion  be  depos- 
ited, as  cotton,  paper,  flour,  iron  ore,  tobacco,  ultramarine  blue. 

Wlien  any  of  the  substances  mentioned  are  inhaled,  a  portion  of  the  dust  is 
entangled  in  the  mucous  membrane  of  the  nasal  passages,  and  to  some  extent  it 
lodges  in  that  of  the  upper  respiratory  passages,  from  which  localities  it  is  grad- 
ually eliminated  by  the  secretion  of  the  nose  and  by  the  act  of  coughing.  If 
the  amount  inhaled  be  not  excessive,  this  may  suffice  to  get  rid  of  all  the  foreign 
matter,  but  as  a  rule  those  who  are  subjected  to  such  unwholesome  conditions 
are  operatives  who  must  continue  for  prolonged  periods  breathing  impure 
air.    In  such  cases  the  ordinary  means  referred  to  are   ineffective,  and  the  for- 


208  AMERICAN  PRACTICE  OF  SURGERY. 

eign  material  reaches  the  lungs.  It  seems  fairly  established  now  that  in- 
haled dust  does  not  reach  the  alveoli  of  the  lung  directly,  for  physical  reasons, 
and  we  have  to  seek  some  other  explanation  for  the  occurrence.  If  we  take,  for 
example,  the  case  of  the  inhalation  of  coal  dust,  as  it  is  met  with  in  coal  miners 
or  those  who  live  in  smoky  cities,  we  find  that  the  excess  of  coal  dust  that  cannot 
be  eliminated  is  deposited  on  the  mucosa  of  the  upper  respiratory  passages, 
where  it  sets  up  a  certain  amount  of  irritation,  resulting  in  cough  and  slight  ca- 
tarrhal inflammation.  Phagocytes  are  attracted  to  the  part,  pick  up  the  pig- 
ment, and  carry  it  along  the  lymphatics  to  the  recesses  of  the  lungs,  where  it  is 
deposited  in  the  alveolar  walls,  the  interlobular  septa,  and  in  the  lower  layer 
of  the  pleura.  In  all  cases  the  process  follows  the  course  of  the  lymphatics. 
From  the  lungs  the  pigment  is  carried  to  the  peribronchial  nodes,  which  become 
coal-black  in  color  and  gritty.  As  a  result  of  the  ij-ritation  produced  in  the  tis- 
sues by  the  foreign  material,  chronic  inflammation  is  set  up,  with  the  formation 
of  connective  tissue.  This  results  in  hardening  of  the  lung,  especially  along  the 
course  of  the  bronchi  and  the  various  septa.  Coal  dust  is  relatively  innocuous, 
but  other  substances,  such  as  iron,  steel,  or  marble,  are  much  more  irritating 
and  lead  to  extensive  induration  of  the  lung  {chronic  fibroid  'pneumonia). 

In  very  extensive  grades  of  the  affection  the  lungs  may  become  hard,  heavy, 
and  may  grate  under  the  knife.  The  lungs  may  even  be  unable  to  retain  the 
great  quantities  of  coal  dust  which,  reach  them,  so  that  the  coal  reaches  the 
general  circulation.  This  takes  place  either  from  the  dust  passing  through  the 
entire  thickness  of  the  vessels  and  mixing  with  the  blood,  or  from  the  softening 
of  anthracotic  lymph  nodes,  with  discharge  of  their  contents  into  some  large 
vein.  The  dust  may  also  get  into  the  general  blood  stream  by  passing  along  the 
lymphatics.  Coal  dust  may  thus  in  time  be  deposited  in  the  liver,  spleen,  or  bone- 
marrow.  Welch  has  described  a  case  in  which  so  much  coal  was  deposited  in  the 
liver  as  to  give  rise  to  a  form  of  cirrhosis  {cirrhosis  anthracotica) . 

The  lungs  of  new-born  and  young  infants  are  devoid  of  this  coal  pigment,  so 
that  its  absence,  or  the  amount  of  it  when  present,  gives  us  approximate  informa- 
tion as  to  the  length  of  time  a  person  has  lived,  and  therefore  may  be  of  some 
value  in  medico-legal  cases. 

The  great  importance  of  the  inhalation  of  dust  ui  connection  with  the  health 
of  workers  in  certain  industrial  occupations  has  led  most  civilized  governments 
to  enact  laws  looking  to  the  providing  of  efficient  ventilation,  and  in  some  cases 
to  enforcing  the  use  of  proper  respirators. 

NECROBIOSIS  AND  NECROSIS. 

Death  of  cells  may  be  gradual  or  sudden  in  its  onset.  Necrobiosis  (indirect 
necrosis)  is  a  term  coined  by  Virchow  to  designate  that  form  of  death  which 
comes  on  slowly,  the  result  of  slowly  acting  causes.    Necrosis  (direct  necrosis)  is 


DISTURBANCES  OF  NUTRITION.  209 

immediate  death.  Both  terms  apply  to  a  local  condition,  in  contradistinction  to 
death  of  the  body  as  a  whole — somatic  death. 

In  the  case  of  necrobiosis,  the  death  of  the  part  is  preceded  by  some  retro- 
grade metamorphosis,  such  as  atrophy,  cloudy  swelling,  fatty  degeneration,  mu- 
coid or  hydropic  degeneration,  or  by  some  pathological  infiltration.  In  direct 
necrosis,  or,  as  it  is  usually  termed  more  shortly,  necrosis,  death  is  rapid  and  is 
not  preceded  by  any  pathological  changes  in  cellular  structure.  It  is  not  always 
easy  to  draw  a  hard-and-fast  line  between  these  antecedent  degenerative  changes 
and  the  resultant  necrobiosis,  or  between  necrobiosis  and  necrosis.  Still  it  is 
well  to  keep  the  ideas  distinct  in  our  minds.  The  preceding  degenerative  proc- 
esses occur  so  gradually  and  are  so  characteristic  in  their  appearances  that  it  is 
usually  thought  better  to  class  them  by  themselves,  and  to  regard  them  as  the 
causes  or,  perhaps  more  correctly  speaking,  the  precursors  of  necrobiosis,  rather 
than  the  necrobiosis  itself.  Necrobiosis  usually  ends  in  necrosis,  and  for  prac- 
tical purposes  may  be  regarded  as  an  incomplete  or  slowly  progressive  necrosis. 

In  a  sense  the  normal  retrogression  of  cells  incident  to  katabolic  processes 
and  the  renewal  of  tissue  is  a  physiological  necrobiosis.  It  is  not  pathological, 
for  it  does  not  interfere  with  function,  the  dead  cells  being  simultaneously  re- 
placed by  new  cells  of  like  kind.  It  may,  however,  be,  and  often  is,  pathological 
when  it  takes  place  independently  of  the  needs  of  the  organism  and  leads  to  more 
or  less  fimctional  disturbance  in  the  part. 

The  causes  of  necrobiosis  are  practically  the  same  as  those  of  necrosis — lack 
of  nutrition,  uifections  and  intoxications,  traumatic,  chemical,  thermal,  and 
mechanical  influences.  Any  of  these  may  act  separately,  or  two  or  more  may  be 
combined.  In  general,  we  may  say  that  deleterious  agencies  of  slight  grade, 
acting  over  prolonged  periods,  are  more  apt  to  produce  necrobiosis  than  necrosis. 

Necrobiosis  may,  no  doubt,  in  slight  grades,  be  perfectly  recovered  from,  but 
many  cases  go  on  to  complete  necrosis.  If,  for  instance,  necrobiosis  has  fol- 
lowed albuminous  degeneration,  simple  necrosis  follows ;  if  there  has  been  ante- 
cedent fatty  degeneration,  soft  caseation  results;  if  hydropic  degeneration  pre- 
ceded, colliquative  or  liquefaction  necrosis  is  the  consequence.  The  results  of 
necrobiosis  are  in  most  cases  those  of  necrosis,  as  one  might  expect. 

Microscopically,  the  cells  undergoing  necrobiosis  present,  in  addition  to  the 
retrograde  manifestations  which  may  have  been  there,  karyorrhexis  of  the  nu- 
clei, with  more  or  less  karyolysis.  This  passes  on  into  actual  disintegration  of 
the  cells. 

Necrosis,  then,  is  death  of  a  cell  or  a  group  of  cells  while  they  are  still  a  part 
of  the  living  body.  In  a  pathological  sense  it  includes  all  those  conditions  vari- 
ously known  as  gangrene,  mortification,  sequestration,  abscess-formation,  ulcer- 
ation, and  caries.  By  surgeons,  however,  these  terms  are  not  generally  used  syn- 
onymously. In  surgical  parlance  "gangrene"  and  "mortification"  are  usually 
taken  to  apply  to  death  of  the  soft  tissues,  while  death  of  bone  is  usually  called 


210  AiIERIC.\N  PRACTICE  OF  SURGERY. 

"necrosis."  It  should  be  mentioned  also  that  gangrene,  mortification,  and 
sequestration  always  imply  death  of  a  part  en  masse.  Gradual,  almost  imper- 
ceptible disintegration,  or  molecular  death,  is  called  ulceration  in  the  case  of  the 
soft  tissues,  and  caries  in  the  case  of  bone. 

As  we  do  not  know  what  constitutes  cell  life,  the  true  nature  of  necrosis,  or 
cell  death,  is  in  a  large  measure  a  sealed  book  to  us.  The  exact  change  in  the 
constitution  of  the  cell  which  mdicates  the  passage  from  life  to  death,  and  the 
time  at  which  it  occurs,  are  beyond  our  ken.  The  methods  of  hardening,  pre- 
serving, and  staining  tissues  in  vogue  at  the  present  time  suffice  to  give  us  fairly 
accurate  information  as  to  the  state  of  the  cells  at  the  time  the  tissues  were 
placed  in  the  solutions.  Of  course  the  cells  are  killed  by  such  methods,  so  that 
we  are  always  studying  dead  material ;  but  what  we  believe  to  be  normal  cells, 
under  such  circumstances,  appear  to  be  so  different  from  others  that  we  are 
able  to  infer,  with  some  approxunation  to  the  truth,  that  certain  cells  were  dead 
while  still  connected  with  the  living  body.  In  all  cases,  however,  we  are  studying 
post-mortem  or  post-necrotic  appearances,  rather  than  the  changes  immediately 
dependent  on  the  necrosis. 

The  exact  chemical  changes  that  underlie  necrosis  are  miknown.  Histolog- 
ically, necrotic  cells  show  mmute  changes  both  in  the  nucleus  and  in  the  cyto- 
plasm. The  nucleus  apparently  breaks  up  into  fragments  (karyorrhexis),  a  form 
of  disintegration  shown  by  Schmaus  and  Albrecht  to  be  preceded  by  a  peculiar 
transposition  of  the  chromatin  threads.  This  gives  place  to  dissolution  of  the 
nucleus  (karyolysis).  The  cytoplasm  loses  its  fuier  structure,  becomes  more 
hyaline  and  opaque,  and  possibly  vacuolated.  Ultimately,  such  cells  may  fuse 
into  an  indistinguishable,  structureless  mass  or  may  liquefy.  In  necrotic  cells 
the  nuclei  stain  badly  as  a  rule,  and  seem  to  be  fading  away.  In  some  instances, 
however,  the  nucleus  contracts  and  stains  more  deeply  than  normal  (pyknosis). 
Thereupon,  the  cell  disintegrates  or  fragments,  and  particles  of  chromatin  are 
liberated,  to  be  disseminated  throughout  the  necrotic  area.  As  a  result  of  this, 
the  dead  tissue,  at  least  in  the  earlier  stages,  may  stain  more  or  less  diffusely 
blue  with  hfematoxylin.  Finally,  the  whole  of  the  cellular  material  is  converted 
into  a  granular  debris. 

The  causes  of  local  death  of  tissue  are  very  various.  They,  however,  may  m 
their  essence  be  reduced  to  two — lack  of  nutrition  and  direct  trauma. 

Traumatic  insults,  by  crushing  or  tearing  the  cells,  lead  directly  to  death  of 
the  part.  Or,  indirectly,  injuries  to  the  blood-vessels  may  interfere  with  the 
adequate  supply  of  blood  to  a  region,  and  thus  necrosis  results.  Probably  in 
most  instances  we  have  to  take  into  account  not  only  direct  influence  of  the  in- 
jury upon  the  cells,  but  also  more  or  less  disorganization  of  the  ordinary  means 
of  circulation.  Wherever  the  blood  supply  is  absolutely  cut  off,  necrosis  is  in- 
evitable. Again,  cells  which  are  dislocated  from  their  normal  environment  are 
very  apt  to  undergo  degeneration  and  necrosis.     Injuries  do  not  always  produce 


DISTURBANCES    OF   NUTRITION.  211 

these  effects  at  the  exact  spot  where  the  injury  has  taken  place.  Thus,  a  cart- 
wheel passing  over  a  limb  may  produce  extensive  laceration  of  the  soft  muscles, 
while  the  skin  remains  intact.  Or  a  crushing  injury  to  the  trunk  may  result  in 
tearing  of  the  liver  or  spleen  without  any  external  manifestations.  In  such 
cases,  if  the  patient  live,  necrotic  changes  in  the  damaged  structures  will  super- 
vene. Again,  severe  blows  upon  the  head  may  lead  to  necrosis  of  the  ganglion 
cells  of  the  brain. 

Injury  to  an  artery  may  be  from  laceration,  pressure,  or  traction.  Should 
the  intima  be  ruptured,  a  thrombus  forms  at  the  site  of  injury,  with  ultimate 
blocking  of  the  vessel  and  necrosis  of  the  supplied  area.  This  is  often  serious, 
for  the  tissues  are  sometimes  so  deteriorated  by  the  injury  that  a  collateral  circu- 
lation cannot  be  formed. 

To  be  classed  with  mechanical  trauma  are  heat,  cold,  and  caustics. 

Tissues  subjected  to  a  temperature  of  from  54°  to  68°  C.  for  a  short  time  will 
undergo  necrosis.  The  effects  produced  by  heat  depend  on  its  intensity  and  the 
length  of  time  during  which  it  is  operative.  Take,  for  example,  a  limb.  The 
least  serious  result  is  an  active  congestion  of  the  part  with  slight  inflammation 
(burn  of  the  first  degree).  If  the  part  be  exposed  somewhat  longer,  the  super- 
ficial epidermis  is  elevated  into  blisters  (burn  of  the  second  degree).  In  this  case 
there  is  necrosis  of  the  epidermis,  which  is  detached  in  parts  from  the  underly- 
ing tissues,  owing  to  the  accumulation  of  serous  fluid.  The  cells  may  show 
hydropic  degeneration.  Or,  the  destruction  of  substance  may  extend  below 
the  skin  (burn  of  the  third  degree) ;  finally,  the  whole  structure  may  be  charred 
(burn  of  the  fourth  degree).  Heat  acts  by  coagulating  the  albumin  of  the  cells 
which  come  under  its  influence. 

Cold  has  an  identical  effect,  the  result  depending  on  its  degree  and  on  the 
length  of  time  the  part  is  exposed  to  it.  Cohnheim  produced  gangrene  of  a  rab- 
bit's ear  by  subjecting  it  for  a  short  time  to  a  temperature  of  16°  C.  Freezing 
will  produce  extensive  gangrene,  especially  in  those  cases  where  the  circulation 
is  not  restored  gradually  and  stasis  results. 

The  x-rays  produce  extensive  and  very  obstinate  burns  in  some  cases.  This 
is  not  the  effect  of  heat,  but  rather  of  some  influence  of  the  chemical  rays,  possi- 
bly, as  has  been  suggested,  upon  the  nerve  endings. 

Caustic  substances,  acids,  alkalies,  acid  nitrate  of  mercury,  chloride  of  zinc, 
will  cause  death  of  the  structures  to  which  they  may  be  applied. 

The  most  numerous  cases  of  necrosis  are  to  be  traced  to  defective  nutrition. 
In  this  connection  interference  with  the  circulation  is  the  most  important  single 
factor.  The  blood  supply  may  be  partially  or  wholly  cut  off  through  an  injury 
to  the  wall  of  the  supplying  artery,  through  thrombosis,  embolism,  arteriosclerosis, 
ligature,  and  pressure  of  tumors  or  of  inflammatory  infiltrations  and  exudates. 
The  return  flow  may  be  obstructed,  as  from  pressure,  inflammation,  or  coagulation 
of  the  blood.     The  capillaries  may  be  occluded  from  similar  causes.     Prolonged 


212  AMERICAN  PRACTICE  OF  SURGERY. 

stasis  of  blood  will  lead  to  death  of  the  affected  parts.  A  weakened  heart  action 
may  be  a  factor  of  greater  or  lesser  importance  in  some  cases.  Familiar  instances 
of  necrosis,  due  in  the  main  to  interference  with  the  circulation,  are:  bed-sores; 
the  local  death  which  follows  too  tight  bandaging,  improperly  applied  splints,  or 
the  pressure  of  an  elastic  stocking;  gangrene  of  the  intestine  from  incarcera- 
tion or  from  torsion  of  a  part.  In  the  cases  of  tumors  the  growth  may  progress 
far  in  excess  of  its  nutritive  supply,  and  gangrene  will  thereupon  follow.  To 
some  extent  mechanical  influences  play  a  part,  as  vessels  may  be  compressed 
or  twisted  in  the  course  of  the  growth  of  a  tumor.  This  is  seen,  for  instance, 
in  the  necrosis  which  occurs  in  the  pedicles  of  pedunculated  fibromata  and 
lipomata. 

Ligation  of  the  principal  arteries,  when  they  are  healthy  and  in  healthy  peo- 
ple, is  attended  by  little  danger  of  gangrene.  The  effect  of  ligation  is  to  rupture 
the  intima  of  the  vessel  and  thereby  to  induce  thrombosis.  The  circulation  is 
quickly  cut  off,  but  usually  sufficient  time  is  given  for  the  establishment  of  a 
collateral  circulation. 

Toxic  agents  of  a  great  many  kinds  may  bring  about  cell  death,  either  by 
their  direct  deleterious  action  upon  the  cellular  protoplasm  or  by  inducing 
changes  in  the  circulation.  Such  substances  appear  to  enter  into  chemical  union 
with  the  protoplasm  of  the  cells  or  intercellular  substance  in  such  a  way  as  to 
render  life  impossible.  The  most  important  are  the  various  bacterial  toxins, 
such  as  those  of  the  staphylococcus,  streptococcus,  typhoid,  diphtheria,  tubercu- 
losis, and  cholera  micro-organisms.  Some  few  are  derived  from  forms  of  animal 
life.  Another  class  includes  toxins  which  result  from  faulty  metabolism  within 
the  body.  Thus,  uric  acid,  the  biliary  acids,  the  abnormal  products  occurring  in 
diabetes  mellitus,  the  pancreatic  ferments,  may,  under  certain  circumstances,  give 
rise  to  necrosis. 

Inflammation  is  not  infrequently  accompanied  by  necrobiotic  and  necrotic 
changes  in  the  tissues.  This  is  due  to  a  variety  of  factors.  We  have,  for  exam- 
ple, the  effect  of  stasis,  alterations  in  the  composition  of  the  blood,  the  toxic  in- 
fluences of  substances  derived  from  bacteria,  and  the  pressure  of  inflammatory 
products. 

Lastly,  necrosis  may,  according  to  some  authorities,  originate  in  the  inhibi- 
tion of  impulses  from  the  central  nervous  system  (neurotrophic  necrosis).  Prob- 
ably in  such  cases  the  death  of  tissue  results  more  from  interference  with  the 
vascular  mechanism  than  from  simple  cutting  off  of  the  trophic  influences. 
Moreover,  once  the  vitality  of  a  structure  is  lowered,  bacteria  readily  make  their 
way  into  it  and  their  influence  must  contribute  to  the  final  result. 

The  causes  just  mentioned  may  act  separately,  but  not  infrequently  several 
are  combined  in  a  given  case.  The  amount  of  necrosis  resulting  depends  upon 
the  nature  and  intensity  of  the  operating  cause,  the  length  of  time  during  which 
it  is  effective,  and  the  vitality  of  the  affected  part.    Tissues  with  weak  resisting 


DISTURBANCES  OF  NUTRITION.  213 

power,  such  as  are  found  in  conditions  of  old  age,  general  anasmia,  cachexia,  and 
marasmus,  may  undergo  necrosis  from  a  trifling  cause. 

The  Forms  of  Necrosis. — The  essential  changes  in  the  cell  which  indicate 
the  presence  of  necrosis  are  destruction  of  the  nucleus  and  more  or  less  disinte- 
gration of  the  cytoplasm.  These  are  present  in  every  case.  These  changes  may, 
however,  be  so  modified  by  or  associated  with  other  processes  that  we  are  able 
to  recognize  different  varieties  according  to  the  gross  or  the  microscopical  appear- 
ances presented.  The  form  of  necrosis  depends  upon  the  position  and  character 
of  the  affected  cells,  the  nature  and  intensity  of  the  causative  agent,  and  the 
nature  of  the  neighboring  tissues.  If  the  dead  cells,  for  instance,  are  on  the  sur- 
face of  the  body,  where  evaporation  can  take  place,  the  cells  become  inspissated 
and  the  part  dry  and  mummified.  If  there  be  an  abundant  supply  of  fiuid,  the 
cells  become  hydropic  and  the  part  may  liquefy.  Again,  the  conditions  may  be 
favorable  for  the  coagulation  of  lymph  and  the  formation  of  fibrin,  either  in  the 
cells  or  in  the  intercellular  substance.  Finally,  the  character  of  the  necrosis  may 
be  modified  by  the  occurrence  of  inflammation  and  the  presence  of  putrefactive 
bacteria.  The  line  of  demarcation  between  these  various  forms  cannot,  however, 
be  always  closely  drawn.    One  form  frequently  passes  imperceptibly  into  another. 

We  may,  however,  recognize  the  following  forms  of  necrosis,  which  are  fairly 
well  to  be  differentiated  the  one  from  the  other : 

(1)  Simple  necrosis.  (2)  Coagulation  necrosis.  (3)  Colliquative  necrosis.  (4) 
Dry  gangrene,  or  mimnnification.  (5)  Moist  gangrene.  (6)  Caseation.  (7)  Fat 
necrosis. 

Simple  Necrosis. — In  this  form  of  necrosis  the  characteristic  features  are  the 
disappearance  of  the  nucleus,  with  hyaline  or  granular  changes  in  the  cellular 
protoplasm.  The  cells  are  often  somewhat  enlarged,  but  their  general  outline  is 
well  preserved.  Occasionally,  the  cells  seem  hyalme  and  homogeneous.  So  far  as 
gross  appearances  are  concerned  organs  so  affected  are  yellowish  or  grayish  in 
color  and  diminished  in  consistency.  The  condition  seems  to  be  an  advanced  stage 
of  cloudy  swelling.  It  may  affect  any  tissue,  but  is  most  commonly  found  in 
the  specific  epithelimn  of  secreting  organs.  The  liver  and  kidneys  are  very  fre- 
quently attacked  in  cases  of  infection  or  intoxication.  Thus,  the  cells  lining  the 
contorted  tubules  of  the  kidney  often  show  marked  necrosis  in  cases  of  mineral 
poisoning  and  in  the  cachexia  of  carcinoma.  Large,  irregular,  necrotic  areas  of 
yellowish  color  are  often  met  with  in  the  liver  in  cases  of  appendicitis  where  in- 
fection has  extended  into  the  portal  vein.  The  so-called  "self-digestion"  of  the 
pancreas,  described  by  Chiari,  presents  an  accurate  picture  of  simple  necrosis, 
but  is  in  most  cases,  if  not  in  all,  a  post-mortem  phenomenon.  Gastric  ulcers 
and  the  local  necroses  following  severe  binns  are  probably  to  be  included  in  this 
category. 

The  so-called  "focal"  necroses  demand  a  word  or  two.  These  are  small  local 
foci  of  cellular  death  found  in  lymph  nodes  and  in  the  various  parenchymatous 


214  AMERICAN  PRACTICE  OF  SURGERY. 

organs,  the  result  of  the  presence  in  the  blood  of  bacteria  or  their  toxins.  The 
condition  was  first  observed  by  Oertel  in  diphtheria,  but  is  met  with  in  other 
affections,  notably  in  typhoid,  tuberculosis,  and  in  the  liver  in  puerperal  eclamp- 
sia. It  has  been  produced  experimentally  by  the  injection  of  the  toxins  of  diph- 
theria, of  ricin,  abrin,  and  of  vegetable  toxalbumins.  Capillary  thrombosis  may 
to  some  extent  aid  in  the  process,  but  the  bacteria  or  their  toxins  are  believed  to 
be  the  chief  causative  factor. 

Coagulation  Necrosis. — There  are  several  forms  of  necrosis  which  have  con- 
siderable similarity,  so  far  as  superficial  appearances  are  concerned.  These  are 
simple  necrosis,  coagulation  necrosis,  hyaline  degeneration,  and  caseation.  They 
all  are  characterized  by  destruction  of  the  cells  and  the  production  of  a  hyaline 
or  granular  structureless  detritus.  By  many  simple  necrosis  is  described  as  co- 
agulation necrosis.  It  is  perhaps  better  to  reserve  the  latter  term  for  that  form 
of  cell  death  in  which  there  is  a  production  of  fibrin  or  fibrin-like  material  (fibri- 
noid degeneration).  That  there  is  such  a  form  of  necrosis  may  be  readily  demon- 
strated by  the  use  of  Weigert's  fibrin  stain.  Coagulation  necrosis  occurs  only  in 
tissues  rich  in  albuminous  substances,  and,  theoretically,  will  result  whenever, 
owuag  to  the  cell  destruction,  fibrin  ferment  is  liberated  to  combine  with  the 
fibrinogen  which  is  present  in  the  lymph.  The  process  is  believed  to  be  prac- 
tically identical  with  that  of  coagulation  of  the  blood  and  the  formation  of  a 
thrombus. 

Two  forms  may  be  distinguished — intercellular  and  intracellular.  In  the 
former,  fibrin  is  formed  between  the  dead  and  dying  cells.  This  fibrin  may  be 
laid  down  in  the  form  of  threads,  granules,  or  hyaline-looking  masses,  along  with 
which  may  be  recognized  the  debris  of  the  original  cells.  The  diphtheria  mem- 
brane may  be  taken  as  the  type  of  this  form  of  necrosis,  which  affects  most 
commonly  mucous  and  serous  surfaces  (diphtheritic,  croupous,  or  membranous 
necrosis).  All  forms  of  inflammation  of  mucous  svu'faces,  associated  with  the 
formation  of  a  membrane,  are  commonly  referred  to  as  diphtheritic,  but  this  is 
somewhat  confusing.  It  is  better  to  restrict  the  term  diphtheritic  to  diphtheria — 
that  is  to  say,  inflammation  due  to  the  Klebs-Loeffler  bacillus — and  to  speak  of 
the  other  forms  as  diphtheroid.  Focal  necroses  in  the  mternal  viscera  are  not  in- 
frequently coagulation  necroses,  and  there  is  also  quite  often  a  formation  of 
fibrin  in  tubercles.  Infarction  less  frequently  gives  rise  to  the  production  of 
fibrin.  Superficial  burns,  if  extensive,  produce  areas  of  coagulation  necrosis  in 
the  spleen  and  lymph  nodes. 

The  second  variety  of  coagulation  necrosis  is  characterized  by  the  transfor- 
mation of  the  parenchymatous  cells  of  an  organ  or  tissue  into  a  solid  or  semi- 
solid albuminous  substance  more  or  less  like  fibrin.  As  an  instance  of  this  we 
may  take  the  so-called  vitreous,  waxy,  or  hyaline  degeneration  of  striated  mus- 
cle, known  as  Zenker's  necrosis.  This  condition  is  fornid  most  often  in  prolonged 
fevers,  such  as  typhoid,  in  some  anamic  infarcts,  in  muscles  which  have  been 


DISTUEBANCES  OF  NUTRITION.  215 

subjected  to  heat  or  cold  or  to  the  influence  of  toxins,  or  which  have  been  torn 
across.  In  the  fevers  the  abdominal  recti,  the  adductors  of  the  femur,  and  the 
ilio-psoas  are  the  parts  most  often  affected. 

Muscles  so  affected  are  semitranslucent  and  of  a  pearly-white  or  grayish 
color  somewhat  resembling  raw  fish.  Microscopically,  the  muscle  fibres  are  swol- 
len, have  lost  their  striations,  and  have  a  hyaline,  homogeneous  appearance. 
The  exact  nature  of  the  process  in  these  cases  is  somewhat  doubtful.  Fried- 
reich, Weigert,  and  others,  look  upon  it  as  a  coagulation  of  the  muscle  plasma; 
others,  as  an  inspissation  of  the  albuminous  constituents.  In  a  few  cases  coagu- 
lation necrosis  may  result  from  the  imbibition  of  fibrinogen-containing  fluids  and 
their  subsequent  coagulation  within  the  cells. 

Colliquative  Necrosis. — In  colliquative  necrosis  or  liquefaction  the  dead  ma- 
terial undergoes  softening  and  to  some  extent  solution.  It  occurs  as  a  primary 
change  or  secondarily  to  some  other  form  of  necrosis.  Colliquative  necrosis  usu- 
ally occurs  in  tissues  freely  supplied  with  lymph  and  containing  but  little  of  the 
fibrin-forming  substances.  It  therefore  is  found  most  often  in  the  skin  and  cen- 
tral nervous  system.  Ansemic  necrosis  of  the  brain  and  cord  is  always  associated 
with  softening.  The  destroyed  nerve-material  is  converted  into  a  soft  detritus, 
consisting  of  fragments  of  cell  chromatin,  droplets  of  myelin,  and  fat,  which 
gradually  become  dissolved  in  the  lymph.  The  necrotic  material  is  often  colored 
from  the  admixture  of  blood  or  blood  pigment  (red  softening,  yellow  softening). 
In  such  cases  absorption  of  the  dead  material  may  take  place,  with,  if  the  area  is 
small,  the  formation  of  a  cicatrix.  Larger  patches  of-softening  become  enclosed 
in  a  fibrous  capsule,  and  a  certain  amotmt  of  the  detritus  is  absorbed,  resulting 
in  the  production  of  a  cyst  filled  with  clear  fluid.  The  softening  that  occurs  in 
thrombi  and  in  the  walls  of  atheromatous  vessels  is  an  example  of  this  form 
of  necrosis.  Liquefaction  is  also  not  uncommonly  found  in  tumors.  Primary 
colliquative  necrosis  is  well  seen  in  burns  of  the  second  degree,  the  first  stage  of 
vesication  being  an  outpouring  of  lymph  and  a  hydropic  degeneration  of  the 
epithelial  cells  in  the  deeper  layers  of  the  skin. 

Liquefaction  necrosis  may  be  secondary  to  simple  or  coagulation  necrosis. 
Fibrinous  exudates,  as  in  pleurisies  and  in  pneumonic  lungs,  in  the  later  stages 
imdergo  softening,  which  is  an  important  factor  in  the  process  of  resolution. 
Areas  of  moist  gangrene  and  caseation  may  imdergo  liquefaction.  In  abscesses 
liquefaction  is  a  constant  feature.  Here,  not  only  do  we  have  the  effects  of  the 
abundant  outpouring  of  lymph,  but  we  have  the  digestant  action  of  ferments 
derived  from  infective  bacteria.  Conversely,  coagulation  may  follow  liquefac- 
tion, the  fibrin-forming  substances  being  derived  from  the  leucocytes. 

Histologically,  areas  of  colliquative  necrosis  show,  in  addition  to  actual  de- 
struction of  the  cells,  vacuolation,  clear  spaces  between  the  cells,  and  a  stringy 
detritus. 

Caseation. — Caseation  is  a  term  applied  more  or  less  loosely  to  designate  that 


216  AMERICAN  PRACTICE  OF  SURGERY. 

form  of  death  of  tissue  which  is  characterized  by  the  production  of  material 
somewhat  resembling  cheese.  It  is  to  be  regarded  probably  as  a  post-ne- 
crotic  change  rather  than  as  a  form  of  necrosis.  Simple  and  coagulation  necrosis 
and  moist  gangrene  may  be  followed  by  caseation.  Caseation  is  fomid  typ- 
ically in  certain  of  the  infectious  granulomata,  notably  tuberculosis.  Somewhat 
similar  changes  occur  in  gummata  and  in  actinomycosis,  and  occasionally  in 
tumors.  Caseous  foci  are  opaciue,  grayish-white  or  yellow,  more  or  less  fu-m 
and  granular,  and  are  cheesy  in  consistence.  If  they  are  hard  and  dry,  we 
speak  of  the  process  as  fhm  or  hard  caseation;  if  the  imbibition  of  fluid  has 
occurred,  we  speak  of  it  as  soft  caseation. 

Microscopically,  we  find  more  or  less  extensive  areas  in  which  the  normal  out- 


FiG.  70. — Caseation  (Tuberculous)  in  the  l.uni;.  i /,. //;  nhj.  No.  3.)  Area  of  caseation  to  the 
right;  the  blood-vessels  injected  to  show  the  avaseularity  of  the  necrotic  part.  {From  the  author's 
private  collection.) 

lines  of  the  cells  and  tissues  are  lost,  the  cells  in  various  stages  of  disintegration, 
with  liberation  of  their  nuclear  chromatin.  In  the  larger  areas  the  central  por- 
tion is  converted  into  a  structureless,  granular  mass,  consisting  of  cellular  de- 
bris, fat,  and  sometimes  calcareous  salts.  In  some  cases  fibrin  is  present.  In  the 
case  of  tuberculous  caseation,  it  is  believed  that  the  necrotic  change  is  due  in  part 
to  obstruction  of  the  nutrient  blood-vessels,  and  in  part  to  the  influence  of  the 
toxins  produced  by  the  bacilli  (see  Fig.  70).  Somewhat  similar  caseation  is  occa- 
sionally observed  in  certain  non-tuberculous  inflammatory  exudates  in  the  lungs. 

Caseous  foci  may  be  completely  absorbed  and  cicatrized.  They  may  soften 
or  become  calcified.  Allien  they  tend  to  heal  they  become  in  time  surrounded 
by  a  fibrous  capsule. 

Fat  Necrosis. — This  is  a  curious  form  of  necrosis  of  considerable  mterest  to 


DISTURBANCES  OF  NUTRITION.  217 

the  surgeon.  In  the  vast  majority  of  cases  fat  necrosis  is  associated  with  some 
lesion  of  the  pancreas,  such  as  pancreatitis,  although  Fitz  holds  that  it  may  oc- 
cur in  the  absence  of  pancreatic  disease.  Experimentally  it  has  been  produced 
by  the  injection  of  pancreatic  extract  into  adipose  tissue,  the  introduction  of 
certain  substances  into  the  pancreatic  duct,  ligation  of  the  pancreatic  vessels, 
the  introduction  of  pieces  of  pancreas  into  fatty  tissues  or  into  the  peritoneal 
cavity,  and  by  the  action  of  steapsin  upon  fat. 

The  necrotic  areas  vary  in  size  from  that  of  a  pinhead  to  a  pea,  are  opaque, 
grayish,  yellowish,  or  sometimes  black  in  appearance.  They  are  usually  sharply 
defined,  and  on  section  are  soft  or  gritty.  Such  areas  may  be  found  in  the  pan- 
creas, in  the  peripancreatic  fat,  in  the  omentum,  and  also  occasionally  in  the  fat 
of  more  distant  regions,  such  as  the  pericardium,  liver,  bone-marrow,  and  retro- 
peritoneal tissues.    In  some  cases  the  pancreas  itself  may  be  free. 

Microscopically,  the  parts  so  affected  show  that  the  fat  cells  are  enlarged  and 
the  nuclei  absent.  The  cellular  substance  is  granular  or  presents  the  appearance 
of  fine  needles  radiating  from  the  centre.  Osmic  acid  does  not  stain  the  necrotic 
material,  while  it  tinges  the  healthy  fat  black  or  brown. 

The  areas  of  fat  necrosis  may  liquefy  or  become  calcified.  The  condition 
usually  ends  m  the  death  of  the  patient,  but  it  may  be  recovered  from.  Extensive 
fat  necrosis  may  be  associated  with  diffuse  hemorrhage  into  the  pancreas  or 
with  sequestration  of  large  portions  of  this  organ. 

The  researches  of  Hildebrand  and  Flexner  have  shown  that  fat  necrosis  is 
due  to  the  liberation  of  the  fat-splitting  ferment  of  the  pancreas.  This  acts  upon 
the  neighboring  fat  to  produce  fatty  acids,  which  ultimately  miite  with  the  cal- 
cium salts. 

Gangrene. — Gangrene,  or  necrosis  of  the  soft  parts,  is  a  term  somewhat 
loosely  employed  by  surgeons  to  designate  certain  peculiar  changes  which  occm- 
in  dead  tissues.  The  leading  featiu-es  of  gangrene  are  that  the  tissues  die  in  bulk, 
and  that  this  death  is  accompanied  b}^  putrefactive  changes  in  the  affected  area. 
A  number  of  other  terms  are  used  also  at  times  to  express  more  or  less  com- 
pletely the  same  imderlying  idea — mortijication,  putrefaction,  putrescence,  sphace- 
lation. 

Gangrene  may  be  primary  or  secondary.  In  primary  gangrene  the  condition 
is  due  to  the  direct  action  on  the  tissues  of  a  micro-organism  having  certain  pe- 
culiar powers,  and  is  to  be  regarded  as  a  specific  infection.  In  secondary  gan- 
grene the  necrosis  is  due  to  some  other  cause,  and  the  affected  part  is  subse- 
quently invaded  by  putrefactive  bacteria. 

The  etiological  factors  at  work  in  the  causation  of  gangrene  are  somewhat 
varied.  The  most  important  single  cause  is  obstruction  to  the  arterial  blood  sup- 
ply of  a  part.  Traumatism,  or  certain  toxic  agents,  or,  again,  bacteria,  may  lead 
to  death  of  a  part  by  direct  local  action.    Other  cases  are  neuropathic  in  origin. 

Primary  gangrene  includes  a  number  of  specific  affections,  such  as  infection 


218 


ajmerican  practice  of  surgery. 


with  the  B.  Welchii,  B.  oedematis  mahgni,  B.  diphtherise,  B.  anthracis,  B.  coh, 
and  some  other  imperfectly  kno-n-n  organisms.  Under  certain  circumstances 
these  germs  have  been  known  to  set  up  severe  local  inflanunation  followed  by 

gangrene  of  the  part.  They  appear  to  be 
competent  to  produce  gangrene  b}^  their  un- 
aided action,  but  in  some  cases  there  may  be 
a  combined  or  secondary  infection  with  putre- 
factive micro-organisms.  On  occasion,  they 
may  be  implicated  in  the  causation  of  second- 
ary gangrene. 

Secondary  gangrene  is  much  the  more  com- 
mon -^-ariet}'.  The  original  necrosis  may  be  due 
to  vascular  disturbances,  alterations  in  the  com- 
position of  the  blood,  pressure,  the  influence  of 
thermal,  chemical,  or  physical  agents,  infection, 
or  neuropathic  disturbances,  the  process  being 
characteristically  modified  by  the  subsequent 
entry  of  parasitic  and  saprophj^tic  micro- 
organisms. 

Anatomically  we  may  recognize  two  main 
varieties  of  gangrene — dry  gangrene  or  mummi- 
ficatioti,  and  moist  gangrene.  Both  forms  are 
essentially  the  same,  any  differences  being  due 
to  varymg  physical  conditions.  Both  are 
forms  of  necrosis  and  both  are  accompanied 
by  putrefactive  changes. 

Many  different  forms  of  gangrene  are  de- 
scribed.    They  may  be  classified  according  to 
etiology,  according  to  their  clinical  coiu'se,  or 
according  to  their  distribution. 
According  to  causes  of  origin  we  have :  (1)  Gangrene  from  vascular  obstruc- 
tion, (2)  traumatic  gangrene,  (3)  inflammatory  and  infective  gangrene,  (4)  neuro- 
pathic gangrene,  (5)  "idiopathic"  gangrene. 

According  to  the  clinical  coui'se  we  may  recognize:  dry  gangrene  (Fig.  71), 
moist  gangrene,  emphysematous  gangrene,  putrid  gangrene,  circumscribed,  dif- 
fuse, spreading,  or  phagedenic  gangj-ene. 

According  to  distribution  may  be  differentiated:  localized  (Fig.  72),  multiple, 
metastatic,  S3mimetrical  gangrene. 

Most  writers  on  systematic  surgery  do  not  adhere  exclusively  to  any  of  these 
modes  of  classification,  but  describe  the  most  striking  clinical  types  on  then- 
merits  without  much  reference  to  the  above  considerations.  It  is  better,  how- 
ever, to  have  some  logical  method. 


Fig.  71. — Dry  Gangrene  of  the  Foot. 


DISTUEBANCES  OF  NUTRITION. 


219 


Among  the  different  forms  of  gangrene  there  is  only  one  concerning  which 
we  shall  take  the  liberty  of  making  a  few  remarks — viz.,  noma.  Presumably 
all  the  different  forms  will  receive  full  consideration  in  the  article  on  Gangrene 
which  is  to  appear  in  a  later  volume. 

Noma. — Noma  (cancer  aquaticus,  Wasserkrebs)  is  a  particularly  rapid  and 
fatal  form  of  gangrene,  which  usually  attacks  the  face  or  the  pudenda.  It  is  found 
without  exception  in  debilitated  or  cachectic  children,  generally  between 
the  ages  of  two  and  twelve,  and  usually  attacks  those  who  are  already 
suffering  from  one  of  the  acute  infective  fevers.  Rarely,  it  may  arise  inde- 
pendently, or  as  a  sequel  of  acute  ulcerative  stomatitis.  Noma  of  the 
face  begins  usually  in  the  buccal 
mucous  membrane  near  the  angle  of 
the  mouth,  occasionally  in  the  gums. 
The  affection  first  makes  its  appear- 
ance as  a  livid,  swollen  patch.  Small 
vesicles  form  and  the  tissues  present 
a  grayish-yellow  inflammatory  in- 
filtration, which  rapidly  breaks  down 
and  becomes  gangrenous.  The  proc- 
ess quickly  spreads  to  the  "skin  of 
the  cheek,  so  that  the  whole  thickness 
of  the  cheek  is  converted  into  a  black- 
ish, necrotic  substance,  about  which 
the  tissues  are  markedly  infiltrated 
and  oedematous.  (See  Fig.  73.)  No 
proper  line  of  demarcation,  in  the  or- 
dinary acceptation  of  the  term,  is 
formed.  The  gangrene  is  usually 
"unilateral,  but  may  extend  to  the 
opposite  side  and  even  attack  the 
bones  of  the  nose  and  jaw. 

At  the  vulva  the  process  usually 
commences  at  the  margin  of  the  labia, 
and  may  eventually  spread  to  the  clitoris,  nymphte,  hymen,  and  urethra.  It 
may  even  invade  the  perineum,  anus,  thigh,  and  mons  veneris,  and,  like  noma  of 
the  mouth,  seems  to  have  a  tendency  to  penetrate  deeply  and  attack  the  bone. 

Noma  may  be  attended  with  high  fever,  chills,  and  great  prostration,  but  the 
special  symptoms  are  not  infrequently  masked  by  those  of  the  previously  exist- 
ing disease.  The  condition  is  exceedingly  fatal,  and  the  patient  usually  sinks 
into  a  state  of  profound  prostration  and  rapidly  succumbs.  Noma  of  the 
mouth  is  said  to  be  occasionally  complicated  by  gangrene  of  the  lungs  and 
enterocolitis. 


Fig.  72. — Gangrene  of  the  Appendix  Vennformis 
in  Acute  Appendicitis  ;  Concretion.  (Pathological 
Museum,  McGill  University.) 


220 


AMERICAN  PRACTICE  OF  SURGERY. 


The  affection  appears  to  be  almost  certainly  of  infectious  nature.  It  not  in- 
frequently occurs  in  epidemics  and  affects  parts  that  are  particularly  exposed  to 
the  action  of  micro-organisms.  The  specific  cause,  if  there  be  one,  has  not  been 
demonstrated  as  yet.  A  bacillus,  resembling  that  of  diphtheria,  has  been  de- 
scribed by  Bishop  and  Ryan  and  by  Schimmelbusch,  but  is  not  invariably  present. 
Babes  and  Zambilovici  have  isolated  from  some  cases  a  pathogenic  micro- 
organism capable  of  mducing  gan- 
grene when  injected  into  rabbits. 
Ranki  and  Lingard  have  also  de- 
scribed a  germ  which  the}^  believe 
to  be  specific. 

Necrosis  of  Bone. — Death  of 
bone  occm's  imder  two  forms — ne- 
crosis and  caries.  Necrosis  is  death 
of  bone  en  7nasse,  and  is  analogous 
to  gangrene  of  the  soft  tissues; 
caries  is  a  gradual  and  almost  im- 
perceptible disintegration  of  bone 
into  fine  particles,  which  may  be 
compared  to  ulceration. 

Necrosis  of  bone  may  be  due  to 
inflammation,  traumatism,  interfer- 
ence with  the  circulation,  thermal 
or  chemical  agents.  Occasionally  the  death  of  the  bone  substance  is  direct, 
but  in  most  cases  there  is  obstruction  to  the  afferent  blood  supply,  however 
it  may  be  produced.  To  this  we  must  add  in  some  cases  the  disintegrating 
action  of  bacterial  toxins. 

Necrosis  of  bone  can,  in  rare  instances,  be  attributed  to  embolism.  The 
circulation  is  under  normal  circumstances  fairly  active,  and  should  a  nutrient 
artery  become  blocked,  a  collateral  circulation  is  readily  established.  In  the 
few  instances  where  necrosis  has  followed  embolism,  the  smaller  arterioles  and 
capillaries  have  been  obstructed.  We  occasionally  see,  in  cases  of  tuberculosis  of 
the  long  bones,  wedge-shaped  areas  at  the  ends,  having  the  base  of  the  wedge 
directed  toward  the  articular  surface.  This  suggests  infarction,  a  view  which  is 
strongly  corroborated  by  the  experiments  of  Mueller.  It  has  been  showTi,  too, 
that  the  articular  surfaces  are  supplied  by  terminal  arteries,  so  that  the  possi- 
bility of  the  occurrence  cannot  be  denied.  Volkmann  met  with  an  instance  of 
multiple  necrosis  of  the  tibia  and  astragalus  in  mitral  endocarditis.  In  such  a 
case  we  probably  have  to  do  with  multiple  capillary  emboli.  These  emboli  may 
be  simple  or  infective.  Simple  necrosis  or  an  abscess  may  thus  result,  or  what 
was  at  first  a  simple  necrosis  may  be  converted  into  one  of  a  suppurative  or 
tuberculous  nature. 


Fig.  73. — Noma   or  Canerum  Oris. 
T.  Bazin.) 


{Case  of  Dr.  A. 


DISTURBANCES  OF  NUTRITION.  221 

Bones  receive  their  nourishment  through  numerous  freely  anastomosing  ves- 
sels situated  in  the  marrow  and  periosteum..  These  are  connected  with  small 
vessels  in  the  Haversian  canals,  so  that  an  abundant  supply  of  blood  is  furnished 
to  every  part  of  the  bone.  Anything,  then,  which  damages  the  medulla  or  peri- 
osteum, or  which  obstructs  the  circulation  within  the  bone  itself,  may  give  rise 
to  necrosis.  Mere  separation  of  the  periosteum  does  not  appear  to  be  competent 
to  produce  necrosis,  but  if  the  sm-face  of  the  bone  be  laid  open  to  the  external 
air,  or  if  there  be  a  suppurative  process  which  has  extended  to  the  Haversian 
canals,  necrosis  will  follow.  Necrosis,  then,  may  result  from  suppurative  peri- 
ostitis, osteitis,  or  osteomyelitis,  or  from  analogous  tuberculous  or  syphilitic 
lesions.  All  these  conditions,  it  will  be  observed,  result  in  compression  of  the 
blood-vessels  from  inflammatory  exudates,  and  may  lead  to  thrombosis  or  to 
endarteritis.  Suppuration  or  ulceration  of  adjacent  parts  may  also  extend  to 
the  periosteum,  and  so  give  rise  to  necrosis  of  the  bone. 

Traumatism  may  produce  necrosis,  provided  that  it  be  of  such  a  nature  as 
to  cause  the  separation  of  portions  of  the  bone  from  their  natural  attachments. 
If  a  bone  be  splintered,  the  minuter  fragments  may  in  time  be  absorbed.  Larger 
ones  may  become  reunited,  provided  that  the  wound  remain  aseptic,  as  has  been 
shown  experimentally  by  Oilier,  Bergmann,  and  others.  This  has  an  important 
bearing  on  the  surgical  procedure  of  transplantation  of  bone.  Experiments 
have  proved  that  detached  pieces  of  bone  may  be  successfully  transplanted 
from  one  part  to  another,  and  even  from  one  animal  to  another,  if  suppura- 
tion do  not  take  place.  This  does  not  invariably  hold  good,  for  Winiwarter 
observed  total  necrosis  of  the  bone  to  take  place  in  two  cases  of  subcutaneous 
dislocation  of  the  astragalus,  in  spite  of  careful  reposition  of  the  parts.  Where 
the  bone  is  extensively  crushed,  vessels  are  lacerated  or  compressed  by 
portions  of  misplaced  bone  or  blood-clot,  and  necrosis  therefore  readily  takes 
place. 

A  good  example  of  necrosis  resulting  from  toxic  or  chemical  agents  is  the 
phosphorus  necrosis.  This  is  met  with  in  people  employed  in  the  manufacture 
of  phosphorus  matches,  and  is  due  to  the  injurious  action  of  the  phosphorous 
vapor.  Phosphorus  necrosis  is  not  so  common  as  it  used  to  be,  owing  to  the 
more  extensive  introduction  of  other  kinds  of  matches  and  the  stricter  enforce- 
ment of  hygienic  measures. 

Phosphorus  necrosis  affects  usually  the  lower  jaw,  less  often  the  upper. 
Lack  of  attention  to  the  cleanliness  of  the  mouth,  and  the  presence  of  carious 
teeth,  predispose  to  the  condition.  The  disease  usually  begins,  as  Wegner  has 
shown,  with  inflammation  of  the  periosteum,  which,  under  the  stimulating  in- 
fluence of  the  phosphorus,  takes  the  form  of  a  hypertrophic  or  productive  peri- 
ostitis. Subsequently,  owing  to  the  action  of  micro-organisms,  infection  takes 
place  with  the  production  of  suppuration  and  secondary  necrosis  between  the 
periosteum  and  the  new  bone  or  between  the  new  and  the  old  bone.    Rarely,  the 


222  AMERICAN  PRACTICE  OF  SURGERY. 

disease  begins  more  acutely  without  the  preliminary  h}^perostosis.  In  time  the 
whole  of  the  lower  jaw  may  become  necrotic. 

The  Mechanism  of  Bone  Necrosis. — \Mien  a  portion  of  a  bone  dies,  it  is  grad- 
ually separated  from  the  living  tissues  and  may  in  time  be  completely  separated 
or  exfoliated.  This  process  is  called  sequestration,  and  the  separated  bone  a  se- 
questrum. Sequestration  results  from  a  process  kno^m  as  lacimar  resorption. 
The  ordinary  breaking  do^\Ta  of  bony  substance  takes  place  through  the  agency 
of  certain  large  cells  called  osteoclasts  (mj-eloplaxes).  These  are  situated  in  the 
bone  marrow  and  the  deeper  layers  of  the  periosteum,  and  erode  their  way  into 
the  bone,  giving  rise  to  minute  excavations,  known  as  Howship's  lacunse.  In 
the  pathological  conditions  of  bone  under  consideration,  these  osteoclasts  are 
greatly  increased  in  numbers  and  lie  closely  packed  together.  Therefore,  rarefy- 
ing osteitis,  as  it  is  called,  leads  to  rapid  destruction  of  the  dead  material,  and 
may  succeed,  in  the  case  of  the  smaller  fragments,  in  completely  removing  it. 
The  process  of  lacunar  resorption  begins  at  the  line  between  the  living  and  the 
dead  material,  and  results  in  the  formation  of  a  line  of  demarcation.  The  peri- 
osteal surface  of  the  sequestrum  often  remains  smooth,  while  the  margins  are 
rough  and  uneven.  The  process  proceeds  centripetalh^,  resulting  in  the  loosen- 
ing of  the  fragment  and  a  more  or  less  marked  diminution  in  its  size.  Inas- 
much as  the  dead  bone  is  to  all  intents  and  purposes  a  foreign  substance,  there 
is  a  certain  amotmt  of  reactive  inflammation  in  the  neighborhood  which  tends  to 
hasten  the  process.  If,  as  is  so  often  the  case,  the  necrosis  be  due  to  inflamma- 
tion, we  may  have  the  formation  of  pus,  which  accumulates  in  and  about  the  se- 
questrum and  in  time  makes  its  way  to  the  surface  of  the  body.  In  this  way 
communication  is  established  between  the  site  of  the  necrotic  process  and  the 
external  air  (sinus,  fistula,  cloaca).  Through  such  fistulse  portions  of  the  dead 
bone,  if  lying  free  upon  the  surface  of  the  bone,  may  make  their  way  to  the  ex- 
terior and  be  cast  off,  and  healing  will  in  many  cases  result.  Sequestra,  however, 
which  lie  in  the  interior  of  the  bone,  if  not  absorbed,  remain  incarcerated  unless 
removed  by  operation. 

Coincidently  with  the  separation  and  removal  of  the  dead  material,  in  cases 
where  repair  is  possible,  there  is  an  attempt  at  the  restoration  of  the  damaged 
part  through  reactive  bone  formation.  The  osteophytes  of  the  periosteum  are 
stimulated  to  increased  activit}^,  so  that  a  capsule  of  newly  formed  bone  is  pro- 
duced around  the  sequestrum  (involucrum).  This  is  particularly  well  seen  in  cases 
of  total  destruction  of  the  shaft  of  a  long  bone,  where  a  complete  new  diaphysis 
may  be  developed  from  the  inner  layer  of  the  periosteum,  which  gradually  restores 
the  continuity  and  configuration  of  the  bone  to  such  a  degree  that  eventually  no 
deviation  from  the  normal  can  be  detected.  This  formation  of  new  bone  is  most 
marked  in  the  case  of  young  and  vigorous  subjects.  Where  a  suppurative  in- 
flammation is  going  on,  pus  may  escape  from  the  cavity  through  the  fistula).  If 
it  be  pent  up,  however,  it  may  in  its  turn  lead  to  further  necrosis,  even  of  the 


DISTURBANCES  OF  NUTRITION.  223 

newly  formed  bone.  In  long-standing  cases,  where  the  power  of  repair  is  very 
marked,  the  inflamed  bone  in  the  neighborhood  of  the  necrotic  part  becomes 
hard  and  eburnated  (sclerosing  osteitis). 

Sequestra  may  be  divided,  according  to  their  situation,  into  external,  or  pe- 
ripheral, and  central.  The  variety  termed  by  Blasius  "necrosis  tubulata"  is 
very  rare.  The  chief  characteristic  is  a  tubular  sequestrum,  the  internal  axis  of 
which  is  formed  of  living  bone  connected  with  the  old  bone. 

Dead  bone  is  dry,  light,  devoid  of  fat,  and  of  a  whitish  color,  owing  to  anae- 
mia.   It  may  be  porous  or,  on  the  other  hand,  sclerosed. 

ULCERATION  AND  CARIES. 

Closely  allied  to  the  conditions  we  have  been  describing,  and,  from  the  pa- 
thologist's standpoint,  practically  identical  with  them,  are  ulceration  and  caries. 
The  terms  gangrene  and  necrosis  connote,  as  we  have  pointed  out  above,  the 
idea  of  death  of  tissue  in  bulk ;  ulceration  and  caries,  as  these  names  are  ordina- 
rily employed,  signify  death  by  the  more  gradual  process  of  molecular  disintegra- 
tion. Authorities  differ  radically  in  their  ideas  as  to  what  constitutes  an  ulcer. 
Billroth  defines  it  as  "a  loss  of  substance,  with  no  tendency  to  heal."  Golding 
Bird  holds  it  to  be  "a  limited  area  of  granulation  tissue  on  the  surface  of  the 
body."  To  my  mind  both  definitions  are  defective,  in  that  they  are  not  suffi- 
ciently comprehensive,  while  to  a  great  extent  they  are  mutually  exclusive.  An 
ulcer  is  none  the  less  an  ulcer  because  it  is  healing,  and,  in  fact,  we  are  constantly 
hearing  the  term  "healing  ulcer."  The  second  definition  is  too  restricted,  inas- 
much as  it  excludes  all  ulcers  which  are  not  granulating,  such  as  phagedenic  and 
the  so-called  "croupous"  ulcers.  Pathologically  speaking,  we  cannot  very  well 
separate  the  condition  known  as  a  granulating  wound  from  a  healing  ulcer,  but 
in  the  surgeon's  mind  there  is  nevertheless  an  underlying  thought  which  distin- 
guishes ulcers  from  all  other  superficial  losses  of  substance.  This  appears  to  be 
the  idea  of  erosion.  Perhaps  we  can  come  very  near  to  what  is  usually  meant 
by  the  term  "ulcer,"  if  we  define  it  to  be  a  superficial  loss  of  substance  of  the 
skin  or  a  mucous  membrane,  which  at  some  or  other  has  shown  a  tendency  to  enlarge 
its  boundaries.  This  definition  would  include  those  cases  excluded  by  the  other 
definitions  referred  to,  and  would  exclude  healthy  granulating  wounds  resulting 
from  traumatism,  while  it  is  at  the  same  time  non-committal  on  the  question 
of  etiology. 

Ulceration  is  the  process  by  which  ulcers  are  produced. 

Etiology.— VlceTS  may  be  brought  about  by  a  great  many  different  factors, 
which  may  operate  singly  or  in  combination.  We  may  consider  the  subject  con- 
veniently under  the  headings  of  (1)  predisposing  causes  and  (2)  exciting  causes. 

Predisposing  causes  are  general  or  local. 

General  Predisposing  Causes.— Age  is  of  no  great  importance  in  determining 


224  AMERICAN  PRACTICE  OF  SURGERY. 

the  frequency  of  ulceration.  One  might  expect  that  ulcers  would  be  relatively 
more  common  in  those  past  middle  life,  considering  the  prevalence  of  retro- 
gressive changes  m  such  persons;  but  this,  in  a  sense  physiological,  tendency  to 
ulceration  in  the  aged  is  more  than  counterbalanced  by  the  frequency  of  tuber- 
culosis and  syphilis  in  the  yoxmg  and  middle-aged,  and  of  traumatism  in  the 
active  period  of  life.  Tlcers  are  said  to  be  three  times  more  prevalent  in  men 
than  in  women.  This  is  probably  due  to  the  greater  liability  to  traumatism  in 
the  case  of  males,  lack  of  cleanliness,  and  the  ravages  of  alcohol  and  syphilis. 
All  occupations  which  expose  to  trauma  and  promote  dirt  would,  of  course, 
predispose. 

Many  constitutional  diseases  and  those  which  lower  vitality  tend  to  invite 
ulceration.  Diabetes,  gout,  anaemia,  scurvj^,  tuberculosis,  and  syphilis  are  im- 
portant in  this  connection.  General  obesity  and  disturbances  of  the  cardio- 
vascular system  have  also  to  be  mentioned. 

Local  Predisposing  Causes. — Of  these,  perhaps  the  most  important  is  im- 
paired circulation.  Atheroma  of  the  arteries,  embolism  or  thrombosis  in  the 
arteries,  veins,  or  capillaries,  often  lead  to  ulceration  by  cutting  off  the  nutrition 
of  the  part.  Small  areas  of  ischsemic  necrosis  may  be  converted  into  ulcers. 
Stasis  in  the  venous  circulation,  especially  if  accompanied  by  oedema,  is  a  potent 
factor  in  bringing  about  ulceration.  Thus,  ulcers  form  on  the  extremities  in  ob- 
structive valvular  disease  of  the  heart  and  varicose  veins.  In  what  way  ulcers 
of  the  lower  part  of  the  leg  should  be  connected  with  varicose  veins  has  been  a 
matter  of  debate.  Varicose  veins  do  not  inevitably  lead  to  ulceration,  so  that 
some  other  factor  must  play  a  part.  Some  find  the  connectuig  link  in  gout; 
others  in  a  local  nem^itis.  Probably  it  is  more  correct  to  find  it  in  the  phlebitis 
and  periphlebitis  which  so  often  come  on  in  the  case  of  varicose  veins,  while 
from  the  superficial  position  of  the  lesion  infection  from  the  skin  is  readily 
brought  about.  Rupture  of  a  vein  with  extravasation  of  blood  into  the  sur- 
rounding tissues  might  cause  ulceration  in  one  whose  tissues  possessed  a  low  re- 
sisting power.  Generally,  too,  these  conditions  occur  in  the  obese,  in  whom  the 
circulation  is  feeble. 

Obstruction  to  the  lymphatic  circulation  may  also  lead  to  ulceration.  This 
is  seen  occasionally  in  cicatricial  closure  of  the  lymphatics  of  a  part  after  opera- 
tions and  in  elephantiasis. 

Trophic  disturbances  in  the  central  or  peripheral  nervous  system  may  also 
be  provocative  of  ulceration. 

Exciting  Causes.  —  These  are  direct  and  local  in  their  character.  Chief 
among  them  should  be  mentioned  traumatism  of  all  kinds,  various  forms  of  in- 
fection, caustics  and  other  toxic  substances,  and  malignant  disease. 

Traumatism. — One  of  the  most  common  direct  causes  of  ulceration  is  injury 
in  some  form  or  other.  The  effect  of  an  injury  will,  of  course,  depend  upon  the 
nature  of  that  injury  and  the  character  of  the  part  affected.    Thus  the  skin  era 


DISTURBANCES  OF  NUTRITION.  225 

mucous  membrane  may  be  destro3^ed  by  a  contusion,  laceration,  the  operative 
removal  of  substance,  by  friction  or  by  a  burn.  In  many  cases  healing  will  begin 
immediately  and  will  progress  by  the  formation  of  healthy  granulations.  If,  how- 
ever, infection  should  be  superadded,  or  should  it  have  existed  from  the  begin- 
ning, the  womid  may  take  on  unhealthy  action  and  tend  to  spread  by  molecular 
disintegration.  On  the  other  hand,  a  much  slighter  injury,  occurring  in  a  person 
of  lowered  vitality  or  in  one  the  subject  of  constitutional  disease  or  poor  circu- 
lation, or  with  deranged  nervous  mechanism,  may  be  followed  by  ulceration. 

Besides  sudden  losses  of  substances  mechanically  produced,  we  have  to  men- 
tion ulceration  resulting  from  pressure,  extreme  heat  or  cold,  x-rays  and  caustics. 

Pressure,  either  from  within  or  from  without,  if  continued  for  a  length  of  time, 
may  produce  ulceration,  partly  by  the  direct  action  on  the  cells  and  partly  by 
cutting  off  the  nutrition.  Bed-sores,  ulcers  from  improperly  applied  splints  or 
orthopedic  apparatus  are  well-known  instances  of  this.  Pessaries  or  other  for- 
eign bodies  m  the  vagina,  calculi  in  the  urinary  bladder  or  the  biliary  passages, 
impacted  fseces  and  fecal  concretions  in  the  appendix  and  bowel,  hard  substances 
introduced  into  the  nasal  passages,  not  infrequently  cause  ulceration.  Deposits 
of  various  salts  beneath  the  skin,  as  in  cases  of  gout,  tumors  growing  from  below 
into  the  skin  or  a  mucous  membrane,  the  filaria  medinensis  or  guinea-worm, 
lead  to  ulceration  of  the  skin.  In  badly-performed  amputations  the  flaps  may 
ulcerate  from  pressure  of  the  end  of  the  bone  or  from  too  tightlj'  drawn 
sutures. 

Caustic  substances,  such  as  acids,  alkalies,  and  certain  acid  salts,  act  by  di- 
rectly killing  the  part  to  which  they  are  applied.  Unless  their  effects  are  cjuickl}' 
neutralized,  the  cells  for  a  considerable  distance  outside  of  the  direct  field  of 
action  may  suffer  in  vitalit)^  and  subsecjuently  die,  thus  leading  to  a  spreading 
ulcer. 

Infection. — Theoretically  it  is  possible  to  conceive  of  ulceration  in  the  ab- 
sence of  infection.  Practically,  however,  since  ulcers  are  found  in  the  skin  and 
mucous  membranes — in  other  words,  on  the  surfaces  of  the  body  which  are  ex- 
posed to  the  attacks  of  micro-organisms — ulceration  and  infection  ahva3's  go  to- 
gether. The  infecting  agents  act  by  converting  what  would  otherwise  be  a  gran- 
ulating or  healing  lesion  into  one  of  a  disintegrating  and  destructive  character. 
The  germs  at  work  aie  usually  the  ordinary  pj^ogenic  or  saprophytic  organisms. 
In  an  analysis  of  one  hundred  cases  of  ulceration  of  the  leg,  Bukovsky  f  omid  the 
B.  pyocyaneus  most  frequently  present.  Other  germs  were  staphylococci,  strepto- 
cocci, B.  coli,  B.  proteus,  and  B.  Friedlanderi  (one  case),  besides  a  few  other 
relatively  unimportant  forms.  Of  course  there  are  several  forms  of  ulceration 
due  to  specific  micro-organisms, — forms  which  are  not  represented  in  this 
analysis,  and  which  usually  receive  separate  consideration,  such  as  syphilis, 
tuberculosis,  actinomycosis,  Madura  foot  disease,  glanders,  leprosy.  Rapidly 
spreading  ulcers,  termed  phagedcenic,  are  due  to  a  particularly  virulent  infection 


226  AMERICAN  PRACTICE  OF  SURGERY. 

in  the  case  of  a  debilitated  subject.  Of  this  type  are  the  hospital  gangrene  and 
the  phagedsena  which  attacks  venereal  sores. 

We  have  to  bear  in  mind  that  infection  may  be  the  primary  cause  of  ulcera- 
tion, as  in  the  specific  diseases  just  referred  to,  in  typhoid,  and  in  chancroid, 
but  not  infrequently  it  is  superadded  to  necrosis  originating  in  another  way. 
Thus  traumatic  losses  of  substance  may  become  secondarily  infected.  Certain 
skin  diseases,  such  as  herpes,  eczema,  ecthyma,  and  pemphigus,  if  situated  in 
parts  of  the  body  which  are  subjected  to  friction  and  imperfectly  cleansed,  often 
lead  to  infection  and  intractable  ulceration.  The  eczema  that  so  often  accom- 
panies varicose  veins  is  an  instance  of  this. 

Ulceration  may  also  be  produced  on  mucous  surfaces  by  the  direct  action  of 
organisms  like  the  B.  typhi,  B.  dysenterite  of  Shiga,  B.  diphtherise,  Amoeba  coli, 
and  the  Plasmodium  of  malaria. 

Parenchymatous  inflammations,  when  not  progressing  satisfactorily  toward 
healing,  may  result  in  ulceration.  A  good  instance  of  this  is  seen  in  the  some- 
what common  event  of  an  abscess  making  its  way  to  the  surface  of  the  body,  or 
"pointing,"  as  it  is  called.  An  abscess  is  a  deep-seated  focus  of  suppurative  in- 
flammation. The  tissues  disintegrate  and  there  is  formed  a  cavity  filled  with  pus. 
This  tends  to  increase  in  size  in  the  direction  of  least  resistance.  The  effect  of  the 
pus  is  to  produce,  first,  pressure,  then  distention  and  stretching,  and,  eventually, 
molecular  disintegration  of  the  structures  which  bar  its  way.  Finally,  in  favor- 
able cases,  the  pus  reaches  the  surface  of  the  body  or  is  discharged  into  some 
hollow  viscus.  In  this  way  healing  is  not  infrequently  accomplished.  The 
process  in  question  may  properly  be  regarded  as  an  ulcerative  one,  inasmuch  as 
there  is  a  molecular  death  of  tissue  which  tends  to  spread.  In  some  cases  the 
nature  of  the  infection  is  such  that  healing  does  not  take  place,  except  by  the 
aid  of  art,  or  else  the  whole  track  of  the  suppurative  process  becomes  specific- 
ally infected  and  a  more  or  less  permanent  external  ulceration  results. 

Syphilis  in  all  its  stages  is  a  potent  cause  of  ulceration.  The  chancre  is  usu- 
ally ulcerative  in  character  and  is  an  example  of  ulceration  from  a  primary  in- 
fection. In  the  secondary  stage  mucous  patches  and  the  various  cutaneous 
lesions  may  in  weakly  and  uncleanly  individuals  be  converted  into  ulcers.  The 
most  typical  syphilitic  ulcer  is,  however,  found  in  the  tertiary  period  in  the 
breaking-down  gumma. 

Tuberculous  ulceration  is  found  both  in  the  skin  and  in  the  mucous  mem- 
branes. Thus,  we  may  have  primary  infection  of  the  tongue,  fauces,  larynx, 
bronchi,  stomach  (rarely),  and  intestines.  The  skin  also  may  be  directly  in- 
vaded by  the  tubercle  bacilli.  Again,  botli  skin  and  mucous  surfaces  may  be 
infected  secondarily  through  the  blood,  or  a  tuberculous  abscess  may  extend  to 
the  surface  and  there  discharge,  forming  a  more  or  less  intractable  ulcer.  Tu- 
berculous ulcers  are  usually  indolent,  with  irregular,  thickened  edges  and  uneven 
base.    The  discharge  consists  of  caseous  detritus  and,  usually,  pus. 


DISTURBANCES  OF  NUTRITION.  227 

In  the  case  of  glanders,  soft  nodules  form  in  the  mucous  membranes,  such 
as  that  of  the  nose,  or  under  the  skin,  and  these  nodules  break  down,  forming 
irregular  ulcers  which  discharge  a  glairy  pus. 

The  adinoviyces  bovis  and  actinomyces  of  Madura  foot  disease  give  rise  to 
similar  lesions,  inflammatory  granulomata,  which,  oAving  to  secondary  infection, 
soften  and  suppurate,  and  when  near  the  surface  often  discharge  externally, 
forming  ulcers. 

The  ulceration  so  characteristic  of  leprosy  is  due  either  to  breaking  down  of 
lepra  nodules,  to  neurotrophic  disturbances,  or  to  the  antesthesia  produced, 
which  renders  it  impossible  for  the  patient  to  perceive  and  avoid  injury. 

Toxic  Ulceration. — Certain  drugs  in  the  course  of  their  elimination  through 
the  emunctories  may  set  up  inflammation  and,  finally,  ulceration.  Such  are 
mercury,  which  produces  ulcerative  stomatitis,  gingivitis  and  colitis;  and  phos- 
phorus, which  causes  ulceration  of  the  buccal  mucous  membrane. 

Ulceration  in  Tumors. — Benign  tumors  may  undergo  necrosis  and  ulceration. 
This  occurs  when  the  tumor  is  so  large  that  its  nutrition  is  impaired,  or  when  its 
pedicle  is  kinked  or  twisted,  thus  interfering  with  the  blood  supply.  Large  pe- 
dunculated fibromata  and  lipomata  not  infrequently  undergo  ulceration.  In  the 
case  of  the  lipomata,  owing  to  the  liberation  of  fatty  acids,  very  foul  ulcers  are 
produced. 

Malignant  tumors,  carcinomata  and  sarcomata,  regularly  break  down,  and, 
if  on  the  surface  of  the  body,  ulcerate  after  they  have  attained  a  certain  size. 
Good  examples  of  this  are  found  in  the  epitheliomata  of  the  skin  and  mucous 
membranes,  rodent  ulcers,  chancroids,  and  melanotic  sarcomata. 

Secondary  malignant  growths  may  extend  from  the  deeper  parts  to  the  skin 
and  mucous  surfaces,  and  then  undergo  necrosis. 

The  Locality  and  Distribution  of  Ulcers. — In  general,  ulcers  are  apt  to  be 
found  in  those  parts  of  the  body  which  are  exposed  to  injury  or  infection,  and  in 
which  the  circulation  is  poor.  Therefore  we  find  them  on  the  uncovered  por- 
tions of  the  body,  at  the  orifices,  in  the  mucous  membrane  of  the  alimentary 
tract,  and  on  the  extremities.  Those  due  to  metastatic  infection,  carcinosis,  or 
sarcomatosis,  are  usually  multiple,  and  may,  of  course,  develop  anywhere.  Ulcers 
are,  therefore,  common  on  the  cornea,  at  the  junction  of  the  skin  and  mucous 
membranes,  as,  for  example,  at  the  angles  of  the  mouth  and  at  the  anus,  on  the 
nipples,  in  the  stomach,  intestines,  the  urinary  and  biliary  passages. 

The  Pathology  of  Ulceration. — The  pathological  process  at  work  in  ulcera- 
tion is  in  the  main  the  same  in  all  cases,  although  it  differs  in  minor  details  ac- 
cording to  the  causative  factor.  There  are  two  opposing  forces  in  operation : 
First,  disintegration  of  tissue ;  and  secondly,  in  most  cases  a  more  or  less  perfect 
attempt  at  repair,  which  manifests  itself  after  a  variable  period.  All  cases  are 
accompanied  by  the  phenomena  of  inflammation.  We  may  recognize  two  great 
classes  of  ulcers — one  in  which  the  destruction  of  tissue  is  the  direct  result  of  cir- 


228  AMERICAN  PRACTICE  OF  SURGERY. 

culatory  disturbance  or  trauma,  to  which  an  inflammatory  process  is  subse- 
quently superadded;  the  other  in  which  inflammation  is  the  primary  cause  of 
the  cellular  disintegration. 

The  first  class  of  cases,  which  are  pathologically  and  etiologically  related  to 
atrophy  and  degeneration,  is  represented  by  the  ulceration  which  is  produced  by 
ischsemic  necrosis  and  gangrene,  passive  congestion  and  oedema  of  tissues, 
contusions,  the  pressure  of  tumors  or  surgical  appliances. 

The  second  class  of  cases  includes  such  conditions  as  the  ulceration  which  re- 
sults from  infected  wounds,  diphtheritic  inflammation,  and  the  specific  granu- 
lomata. 

Owing  to  the  great  variety  of  the  causes  that  produce  ulceration  and  the  dif- 
ferences in  the  local  reaction,  it  is  impossible  to  give  one  description  which  will 
apply  to  all  cases.  It  will  therefore  be  better  to  indicate  the  chief  types.  We 
may  classify  ulcers  according  to  their  etiology  or  according  to  their  appearance 
and  clinical  course. 

According  to  etiology  we  can  recognize  traumatic  ulcers,  ulcers  from  stasis, 
inflammatory,  gouty,  scorbutic,  neuropathic,  and  malignant  ulcers. 

It  is  perhaps  more  usual  in  practical  works  on  surgery  to  classify  ulcers  ac- 
cording to  their  clinical  features.  Thus  we  have  the  simple,  healthy,  or  healing 
ulcer,  the  rveak  or  oedematous  ulcer,  the  mflamed  ulcer,  the  chronic  callous  or 
indolent  ulcer,  the  fungous  ulcer,  the  irritable  or  painful  ulcer,  the  sloughing  or 
-phagedcenic  ulcer,  varicose,  eczematous,  gonty,  scorhitic,  specific,  and  malignant  ul- 
cers. These  terms  indicate  in  part  the  particular  causes  of  the  ulceration,  and  in 
part  their  special  characteristics,  due  to  local  conditions  and  surroundings.  The 
local  conditions  are,  however,  liable  to  change  from  day  to  day,  so  that  various 
gradations  occur  between  the  various  forms  of  ulcers,  and  even  the  type  itself 
may  change  from  time  to  time.  For  example,  a  callous  ulcer  may  be  trans- 
formed into  a  phageda^nic  one. 

The  Simple  Ulcer. — This  may  be  taken  as  the  type  of  all  ulceration.  Others 
differ  from  it  merelj'  in  detail,  and  all  ulcers  tend  when  healing  to  approach  this 
form.  The  base  of  the  ulcer  is  level  or  nearly  so,  and  covered  with  healthy  gran- 
ulations. The  edges  are  smooth  and  shelving.  The  newly  formed  epidermis, 
destined  to  cover  the  damaged  area,  can  be  seen  at  the  borders  as  a  thin,  bluish- 
white  film.  The  discharge  is  creamy,  inodorous  pus,  or  possibly,  if  the  ulcer  be 
kept  clean  and  dressed  antiseptically,  serum. 

Microscopicall}',  the  base  of  the  ulcer  consists  in  the  main  of  inflammatory 
round  cells,  together  with  some  spheroidal  and  epithelioid  cells.  On  the  surface 
may  be  pus  cells,  fibrin,  cell  debris,  and  dried  serum.  Deeper  down  we  find 
greater  amounts  of  connective  tissue,  with,  if  the  ulcer  be  healing  satisfactorily, 
young  fibroblasts.  Newly-formed  capillaries  are  also  present,  in  the  form  of  ver- 
tical sprouts  and  loops  extending  in  the  direction  of  the  surface.  Round  about 
the  ulcer  will  be  found  a  variable  amount  of  connective  tissue  or  scar  tissue, 


DISTURBANCES  OF  NUTRITION.  229 

which  contracts  as  the  ulcer  heals.  At  the  margin  the  epithelium  is  proliferating 
by  division  of  the  cells.  In  the  case  of  the  skin  proper,  the  papilla?  are  not  repro- 
duced nor  are  the  hair  follicles  and  various  glands. 

As  the  process  of  healing  progresses,  more  of  the  round  cells  are  produced 
than  necessary,  and  are  cast  off  in  the  discharge.  Loops  of  blood-vessels  are 
abundantly  produced  and  carry  along  with  them  numerous  fibroblasts,  which 
are  to  be  converted  into  cicatricial  tissue.  Fibrous  tissue  is  produced  in  in- 
creasing amount,  and  the  epithelium  gradually  extends  over  the  raw  surface 
until  the  loss  of  substance  is  made  good.  Finally,  many  of  the  blood-vessels 
disappear,  and  the  scar  contracts,  becoming  firm,  pale,  and  ansemic. 

The  Weak  or  (EdemaMis  Ulcer. — Any  ulcer  may  become  weak  if  healing  be 
too  long  delayed.  This  form  is  generally  found  in  connection  with  tuberculous 
bones  and  joints.  The  edges  and  tissues  about  the  ulcer  are  generally  healthy, 
but  the  granulations  on  the  surface  are  abundant,  flabby,  semitranslucent, 
cedematous,  and  friable.    The  discharge  is  watery  and  free. 

The  Fungous  or  Exuberant  Ulcer. — Here  the  edges  are  healthy,  but  the  gran- 
ulations rise  above  the  surface,  are  tumid,  dark  red,  redundant,  and  easily  bleed. 
The  condition  is  usually  due  to  some  obstruction  in  the  return  venous  circula- 
tion. 

The  Inflamed  and  Inflammatory  Ulcer. — In  these  ulcers  inflammation  is  the 
most  striking  feature.  The  inflammation  may  result  from  some  constitutional 
vitium,  as  from  alcoholism,  improper  and  insufficient  food  and  other  causes  of 
impaired  nutrition,  or  from  any  local  cause  of  irritation.  Inflammatory  ulcers 
are  irregular  in  shape;  the  edges  are  ragged  and  shreddy  or  sharplj^  defined. 
The  base  is  dry,  dull  red,  devoid  of  granulations,  covered  with  serous  or  sanious 
discharge,  sometimes  with  yellowish  sloughs.  The  surrounding  tissues  are  swol- 
len, red,  and  hot. 

The  Sloughing  or  Phagedenic  Ulcer. — This  is  a  more  intense  form  of  the  in- 
flammatory ulcer.  The  destructive  processes  are  greatly  in  the  ascendant,  and 
the  inflammation  is  of  quickly  spreading  and  infective  character.  The  base  is 
devoid  of  granulations,  secretes  an  ichorous  discharge,  and  is  converted  into  an 
ashen-gray  or  black,  sloughy  material.  The  edges  are  irregular,  swollen,  and 
undermined.  The  process  appears  to  be  clue  to  a  specific  micro-organism,  as  the 
ulceration  proceeds  with  extraordinary  rapidity  unless  checked  by  appropriate 
measures.  There  is  usually  also  considerable  constitutional  disturbance.  This 
form  of  ulceration  is  seldom  seen  except  in  connection  with  venereal  disease  in 
those  with  broken-down  constitutions. 

The  Chronic,  Callous,  or  Indolent  Ulcer. — An  ulcer  may  become  indolent  as  a 
result  of  long-continued  irritation.  The  edges  of  such  an  ulcer  are  smooth, 
white,  hard,  rounded,  and  insensitive,  and  they  are  indurated  from  the  pres- 
ence of  inflammatory  products,  so  that  the  circulation  is  impaired  and  healing 
prevented.    The  neighboring  tissues  are  congested,  and  the  skin  is  often  excori- 


230  a:\iericax  practice  of  surgery. 

ated  or  eczematous.  Granulations  are  either  absent  or  are  scanty,  small,  and 
badh'  formed.  The  discharge  is  thin  and  sanious.  Indolent  ulcers  are  com- 
monly fomid  m  the  lower  third  of  the  leg,  may  exist  for  years,  and  are  attended 
by  but  little  pain.  They  may  be  small  or  may  gradualh'  extend  round  the  limb. 
Sometimes  the}-  become  adherent  to  the  fascia,  periostemri,  or  bone.  \Mien 
verj'  old  or  when  subjected  to  constant  irritation,  they  maj'  take  on  epithe- 
liomatous  action. 

The  Irritable  or  Painful  Ulcer. — Any  ulcer  may  be  irritable  and  painful  or 
may  become  so,  but  the  term  "irritable"  is  generalh'  restricted  by  surgeons  to 
painful  fissm'es  about  the  anus  and  to  a  small,  superficial,  congested  ulcer,Jound 
usually  in  women  after  middle  age,  near  the  ankle.  The  pain  is  extreme  and  is 
believed  to  be  due  to  involvement  of  the  nerve  endings. 

Varicose  and  Eczematous  Ulcers. — This  form  of  ulceration,  as  the  names  im- 
ph%  is  associated  with  varicose  veins  and  eczema.  Both  conditions  are  not 
infrequenth^  foimd  together. 

Gouty  Ulcers. — Goutj-  ulcers  are  fomid  over  uratic  deposits.  They  are  small 
and  superficial,  and  the  discharge  contains  sodium  urate,  which  it  deposits  as  a 
chalk-like  material  about  the  ulcer. 

The  Scorbutic  Ulcer. — The  sm'face  of  a  scoi'butic  ulcer  is  covered  with  a 
spong}^,  dark,  adherent,  fetid  crust.  "\^lien  this  is  removed  the  surface  bleeds 
freely  and  the  same  material  is  reproduced. 

Specific  Ulcers. — These  include  tuberculous  and  syphilitic  ulcers. 

The  former  are  generalh^  multiple  and  often  confluent.  In  the  neighborhood 
can  sometimes  be  formd  traces  of  former  ulcers  in  the  form  of  scars  and  depres- 
sions. Tuberculous  ulcers  are  generally  due  to  the  breaking  do'mi  of  tuberculous 
nodes,  with  discharge  of  their  contents  externalh^  The  granulations  are  pale, 
cedematous,  protruding,  and  bleed  freely  when  touched.  The  discharge  is  scanty, 
thin,  and  yellowish-green  in  color.  The  edges  are  pale,  thin,  and  undermined. 
Lupus,  or  tuberculosis  of  the  skin,  is  described  elsewhere. 

Syphilitic  ulcers,  with  the  exception  of  the  prmiary  sore,  are  divided  into 
superfi.cial  and  deep.  The  superficial  are  usually  associated  with  syphilitic  erup- 
tions. They  are  circular  or  crescentic  in  shape,  or,  when  several  have  coalesced, 
.serpiginous  or  annular.  Thej'  spread  by  their  convex  aspect,  while  the  older 
portions  tend  to  heal.  The  base  of  such  ulcers  is  but  slighth^  depressed,  of 
dark  reddish  color,  and  is  covered  with  a  scab  or  slough.  The  edges  are  sharply 
cut  and  surrounded  by  a  dull  reddish  areola. 

Deep  syphilitic  ulcers  are  due  to  the  breaking  down  of  gummata.  They  are 
oval  or  circular  in  shape.  The  base  is  depressed  and  covered  with  a  yellowish 
slough  resembling  wet  wash-leather.  The  edges  are  steep,  well-defined,  slightly 
excavated,  and  of  a  dull  reddish  appearance. 

Malignant  Ulcers. — These  include  epithelioma,  carcinoma,  sarcoma,  and 
rodent  ulcers.     They  are  described  elsewhere.     In  general  it  may  be  said,  how- 


DISTURB.\NCES  OF  NUTRITION.  231 

ever,  that  benign  growths  may  produce  ulceration  from  pressure  on  the  skin 
arising  in  the  course  of  their  growth,  or  from  impairment  of  the  circulation 
within  them.  In  the  case  of  malignant  tumors, "when  ulceration  occurs,  it  is  clue 
to  the  breaking  dowm  of  the  cells  proper  of  the  growth.  The  surrounding  tissues 
may  in  time  be  invaded  by  the  new  growth,  and  this  freshly  formed  material 
may  in  its  turn  break  down.  Usually  in  such  cases  there  is  more  or  less  inflam- 
mation, with  its  ordinary  phenomena  superadded.  Both  primary  and  second- 
ary new  growths  may  attack  the  skin  and  mucous  membranes  and  undergo 
necrosis.  Chronic  ulcers  in  elderly  people  and  lupous  patches  may  at  times 
undergo  epltheliomatous  transformation. 

There  are  a  few  forms  of  tropical  ulcers,  mostly  of  uncertain  etiology,  about 
which  a  word  or  two  may  not  be  out  of  place  here. 

Veldt  sores  are  a  form  of  ulcer  common  among  the  British  troops  during  the 
recent  war  in  South  Africa.  The  sores  are  found  on  the  exposed  parts  of  the 
body,  the  hands,  forearms,  and  feet.  They  appear  to  begin  in  the  deeper  layers 
of  the  epidermis,  and  at  first  resemble  a  bleb  abrasion.  Later,  a  slowly  spread- 
ing, chronic  ulcer  is  formed.    The  etiology  is  still  imder  discussion. 

Delhi  sore  is  met  with  in  India,  Central  Asia,  the  Levant,  Algeria,  and  the 
Malay  peninsula.  It  is  found  on  some  exposed  portion  of  the  body,  and  begins 
as  one  or  more  papules,  which  become  pustular  and  finally  develop  into  ulcers. 
The  ulcers  may  be  multiple  and  may  fuse  together.  The  base  is  usually  irregu- 
lar, healing  in  one  place  and  spreading  in  another.  The  edge  is  thickened,  ragged, 
and  surrounded  by  an  areola  of  inflammation.  The  ulcer  runs  a  very  sluggish 
course.  Wlien  it  heals  it  leaves  a  depressed  scar,  puckered  in  the  centre,  and  of 
a  bluish-brown  color. 

Annani  ulcer  is  a  variety  of  phagedtena  found  m  Annam,  Aden,  Cochin  China, 
and  Mozambique.  It  usually  begins  on  the  foot  or  leg  as  an  area  of  infection. 
This  sloughs  and  a  more  or  less  rapidly  spreading  ulcer  is  produced.  The  base 
is  covered  with  unhealthy  granulations,  which  bleed  at  the  slightest  touch, 
or  with  a  grayish  pseudo-membrane,  and  discharges  fetid  pus.  The  edges 
are  undermined.  Both  base  and  edges  may  be  extensively  gangrenous,  and  the 
ulcer  may  penetrate  deeply.  The  cause  is  unknown,  but  syphilis,  antemia,  bad 
hygienic  conditions,  are  believed  to  predispose. 

Gaboon  ulcer  is  found  in  natives  of  the  Gaboon.  It  occurs  on  the  limbs  and 
is  similar  to  a  syphilitic  ulcer. 

Dracuncular  ulcer  is  endemic  in  parts  of  India,  Ai'abia,  Bokliara,  Turkestan, 
tropical  Africa,  and  South  America.  It  is  due  to  the  Filaria  medinensis,  or 
Guinea-worm,  a  species  of  thread-worm.  This  is  a  very  large  filaria,  averaging 
three  feet  in  length,  but  may  be  as  much  as  six  feet  long.  It  lives  in  the  sub- 
cutaneous tissues.  The  female  worm,  which  is  the  one  that  causes  the  trouble, 
as  she  approaches  maturity,  works  her  way  to  the  surface,  usually  in  the  leg, 
foot,  or  ankle.    She  then  discharges  her  eggs  and  penetrates  the  skin,  forming  a 


232  AMERICAN  PRACTICE  OF  SURGERY. 

sort  of  bulla  on  the  surface.  This  becomes  infected,  breaks  down,  and  forms  an 
ulcer  with  a  minute  hole  in  the  centre,  through  which  part  of  the  worm  may- 
protrude. 

Complications  and  Sequelss  of  Ulceration. — Cellulitis  or  erysipelas  may  at- 
tack the  tissues  about  an  ulcer.  Hemorrhage  from  an  ulcer  is  not  uncommon, 
especially  in  varicose  cases.  It  has  been  fatal.  Wlien  an  ulcer  has  healed,  the 
resulting  cicatrix  may  be  the  cause  of  serious  trouble.  Thus,  it  may  lead  to  un- 
sightly deformities  and  distortion  when  on  the  face  or  neck ;  when  it  is  situated 
near  a  joint,  more  or  less  ankylosis  may  result.  Keloid  may  also  develop  in 
the  scar  of  an  ulcer.  Ulceration  may  lead  to  destruction  of  important  struct- 
ures, such  as  bones,  cartilage,  joints,  muscles,  and  it  may  also  cause  infection 
of  lymphatic  vessels  and  nodes.  Profound  constitutional  disturbance  and 
weakness  may  result.  Ulcers  affecting  the  hollow  viscera,  such  as  the  stomach 
and  intestines,  may  perforate,  giving  ri,se,  unless  protective  adhesions  be  formed, 
to  fatal  peritonitis.  Chronic  ulcers,  or  those  which  have  healed,  may  cause 
stenosis  of  the  lumen  of  the  bowel. 

Caries  of  Bone. — Analogous  to  ulceration  of  the  soft  tissues  is  the  molecular 
disintegration  of  bone  known  as  caries. 

Caries  is  a  chronic  process  of  gradual  softening  or  breaking  down  of  bony 
substance,  and  is  in  all  cases  the  result  of  inflammation.  Infective  agents  are 
brought  to  the  bone  by  the  blood  stream,  and  are  deposited  in  the  smaller  vessels 
in  the  bone  spaces.  The  ordinary  phenomena  of  inflammation  result,  save  that 
swelling  cannot  occur,  owing  to  the  unyielding  nature  of  the  tissue.  Pressure, 
interference  with  the  nutrition  of  the  part,  and  the  toxic  emanations  from  the 
bacteria,  all  combine  to  bring  about  the  death  of  the  part.  The  products  of  in- 
flammation are  thrown  off,  mixed  with  calcareous  matter  and  particles  of  decal- 
cified bone  in  the  form  of  sand  or  grit  (molecular  necrosis  of  bone — von 
Volkmann).  Actual  loss  of  substance  thus  occurs.  Caries  is  met  with  most 
commonly  and  typically  in  connection  with  tuberculosis,  syphilis,  actinomycosis, 
acute  and  chronic  osteomyelitis,  and  in  suppurative  processes  extending  to  the 
bone.  When  there  is  a  dry,  cheesy  sort  of  detritus  produced  without  pus,  we 
have  what  is  known  as  caries  sicca.  Or,  the  carious  process  may  so  extend  as 
to  encircle  a  considerable  area  of  bony  substance,  which  it  thus  deprives  of 
nutrition.  As  a  result  a  large  sequestrum  is  formed.  This  is  termed  caries 
necrotica.  Molecular  necrosis  is  met  with  more  particularly  in  association  with 
acute  suppuration  and  where  the  granulation  tissue  is  of  low  vitality,  direct 
death  of  small  particles  of  bone  resulting.  The  finer  details  of  the  process  in 
caries  are  largely  a  matter  of  speculation.  Billroth  thought  that  the  essential 
factor  was  the  resorption  of  the  bone  by  the  cells  of  the  granulation  tissue.  Von 
Volkmann  believed  that  the  bone  is  disintegrated  by  the  chemical  solution  of 
the  ground  substance  with  the  liberation  of  the  calcareous  salts. 

A  similar  obscurity  befogs  the  subject  of  ulceration  of  the  soft  tissues. 


DISTURBANCES  OF  NUTRITION.  233 

Ulceration  cannot  take  place  in  healthy  tissues.  There  must  be  some  previously 
existing  disturbance  which  impairs  vitality..  If  inflammation  be  not  the  dis- 
turbing factor  in  the  first  instance,  it  quickly  becomes  associated  with  the 
process.  Breaking  down  of  tissue  is  for  a  time  at  least  in  excess.  How  is  the 
dead  material  disposed  of?  Two  methods  are  conceivable.  Either  it  may  be 
disintegrated  and  cast  off  externally,  or  it  may  be  absorbed.  No  doubt  both 
methods  are  at  work,  but  the  former  seems  to  be  by  far  the  more  important.  In- 
asmuch as  material  to  be  removed,  such  as  portions  of  epidermis,  fragments  of 
bone  or  of  soft  tissue,  are  usually  cast  off  rather  than  absorbed,  we  may  infer 
with  some  certainty  that  the  same  general  rule  holds  good  in  regard  to  ulceration 
and  caries.  It  is,  in  fact,  not  uncommon  to  recognize  small  particles  of  bone  or 
other  tissue  in  the  discharge  from  ulcers,  while  in  certain  cases  considerable  areas 
of  dead  tissue — sloughs,  as  they  are  called — are  produced,  which,  when  they  are 
cast  off,  leave  an  ulcerating  surface  beneath.  Thus  we  have  all  possible  grada- 
tions between  an  impalpable  disintegration  of  tissue  (molecular  necrosis,  or  ul- 
ceration in  the  strict  sense)  and  the  separation  of  visible  particles  or  larger 
masses  (sloughing  or  gangrene).  The  importance  of  the  external  discharge  of 
dead  material  is  seen  particularly  well  in  the  case  of  abscesses,  which  may  in  a 
sense  be  regarded  as  concealed  ulcers.  Wherever  possible,  the  pus  burrows  its 
way  to  the  surface  of  the  body  or  to  some  hollow  viscus,  and  is  there  evacuated 
and  removed.  Healing  in  many  cases  will  then  occur  spontaneously.  If  this  do 
not  occur,  in  many  cases  the  abscesses  are  not  absorbed,  but  go  on  extending. 
Indeed,  only  the  smaller  foci  of  suppuration  can  be  removed  by  absorption, 
and  that  often  imperfectly. 

With  regard  to  the  cjuestion  of  absorption,  we  cannot  altogether  deny  that  it 
is  of  some  importance.  No  doubt  the  excretions  or  discharges  from  certain  ul- 
cers, inasmuch  as  they  contain  enzymes  derived  from  bacteria,  are  competent 
to  bring  about  solution  of  the  tissues,  although  it  is  not  likely  that  this  invariably 
occurs,  as  Rokitansky  used  to  think.  Now  if  such  discharges  be  pent  up,  the 
disintegration  process  often  proceeds  apace,  as  we  have  so  often  opportunity  to 
note  clinically,  and  in  some  cases  the  products  of  disintegration,  together  with 
septic  matter,  are  absorbed  into  the  circulation,  partly  through  the  lymph  stream 
and  partly  through  the  agency  of  the  phagocytes.  Proof  of  this  is  fovmd  in  the 
cases  of  cellulitis,  erysipelas,  and  septico-pysemia  which  occasionally  complicate 
ulceration.  The  removal  of  inflammatory  products  in  other  forms  of  inflamma- 
tion— a  process  which  is  so  constant  an  accompaniment  in  the  process  of  repair 
— would  induce  us  to  think  that  a  somewhat  similar  state  of  affairs  is  present 
in  ulceration. 

DISTURBANCES  OF  THE  CIRCULATION. 

The  circulation  of  the  blood  throughout  the  body  is  carried  on  by  means  of  a 
muscular  force  and  suction  pump — the  heart, — with  which  is  connected  an  elab- 


234  AMERICAN  PRACTICE  OF  SURGERY. 

orate  system  of  more  or  less  elastic  tubes — the  arteries,  capillaries,  and  veins. 
Within  the  vascular  system  the  blood  pressure  is  dependent,  first,  on  the  force 
of  the  contractions  of  the  heart  muscle,  and,  secondly,  on  the  amount  of  resist- 
ance manifested  in  the  peripheral  vessels.  The  blood  pressure  is  greatest  within 
the  heart  dxiring  systole,  and  falls  gradually  in  the  arteries,  capillaries,  and  veins, 
in  the  order  named.  It  is  least  at  the  venous  orifices  of  the  heart  during  dias- 
tole. The  blood  pressure  is  also  governed  to  a  large  extent  by  the  elasticity  of 
the  vessels  and  the  degree  of  their  tone.  The  amount  of  blood  in  any  part  de- 
pends, in  addition  to  the  influence  of  muscular  action  and  elasticity,  upon  the 
vasomotor  nerve  mechanism,  which  determines  the  calibre  of  the  vessels,  their 
distensibility,  and,  hence,  their  capacity.  The  circulation  is  apt  to  be  feeblest 
in  those  parts  of  the  body  which  are  most  remote  from  the  heart,  and  in  the 
dependent  portions.  Under  ordinary  circumstances,  the  blood  pressure  and  the 
amount  of  blood  in  any  given  part  vary  according  to  the  nutritive  and  functional 
needs.  The  circulation  may  be  deranged  by  causes  which  interfere  with  the  on- 
ward flow  of  the  blood  and  lymph.  These  may  be  systemic  or  local  in  their 
operation.     Or  the  blood  itself  may  be  altered  in  amount  or  in  quality. 

Hypersemia,  or  Congestion. — The  amount  of  blood  in  any  given  part  varies 
considerably  even  within  physiological  limits,  according  as  to  whether  the  func- 
tion of  the  part  is  active  or  in  abeyance.  Should  the  amount  exceed  or  fall  below 
these  limits,  owing  to  causes  other  than  physiological  ones ;  or  should  the  varia- 
tion persist  for  an  abnormal  length  of  time,  then  we  speak  of  pathological  disor- 
ders of  circulation.  An  excess  of  blood  is  called  hypermmia  or  congestion;  lack 
of  blood  is  called  anmnia,  or,  more  correctly,  ischamia. 

Hypersemia  may  be  general  or  local.  General  hypercemia,  or  plethora,  as  it  is 
called,  is  rare,  if  it  can  be  said  to  occur  at  all.  Now  and  then  we  meet  with  in- 
dividuals whose  circulatory  system  seems  to  be  overfilled.  Especially  do  we  see 
this  in  those  who  have  died  from  obstructive  heart  affections.  There  seems  to  be 
more  blood  than  usual  in  the  body,  although  it  is  certainly  not  normal  blood. 
During  life,  however,  any  excess  in  the  total  quantitj^  of  the  blood  is  quickly 
compensated  by  increased  activity  of  the  emunctories. 

Local  hypercemia  may  be  due  to  an  excessive  supply  of  arterial  blood — active 
hyperemia;  or  to  some  obstruction  to  the  outflow  of  venous  blood — passive  or 
venous  hypercemia. 

Active  hyperaemia  results  from  a  variety  of  causes,  among  which  may  be 
mentioned  increased  heart  action,  dilatation  of  the  arteries  of  a  part,  stimula- 
tion of  the  vasodilator  nerves,  paralysis  of  the  vasoconstrictor  nerves,  the 
diminution  of  extravascular  pressure.  It  is  seen  particularly  well  in  the  first 
stages  of  inflammation.  Irritations  of  all  kinds,  such  as  those  produced  by 
traumatism  and  by  chemical,  thermal,  and  mechanical  influences,  are  competent 
to  produce  congestion.  Local  ana-mia,  when  continued  for  any  length  of  time, 
is  usually  followed  by  hypersemia.    The  removal  of  long-continued  pressure  upon 


DISTURBANCES  OF  NUTRITION.  235 

blood-vessels  is  succeeded  conimonly  by  arterial  dilatation  and  congestion. 
Thus,  the  application  of  an  Esmarch  bandage  is  followed  by  arterial  dilatation  on 
its  removal.  The  sudden  removal  of  fluid  from  the  chest  or  abdomen  is  followed 
by  local  active  hypersemia,  which  may  be  so  extreme  as  to  cause  faintness,  owing 
to  the  collateral  ansemia  of  the  brain  that  results.  Closure  or  narrowing  of  an 
artery  leads  to  collateral  hypersemia  of  the  adjacent  parts.  The  pressure  of 
tumors,  of  enlarged  lymph  nodes,  or  of  inflammatory  products  upon  the  sympa- 
thetic nerve  ganglia  or  fibres,  sometimes  causes  arterial  hypersemia,  owing  to 
paralysis  of  the  vasoconstrictor  nerves. 

A  part  affected  by  arterial  hypersemia,  if  on  the  surface  of  the  body,  is  of  a 
more  or  less  deep  red  color,  and  is  somewhat  warmer  than  the  siurounding 
structures.  In  many  instances  nutrition  is  stimulated,  and  probably  function  is 
increased. 

Local  venous  hypersemia,  or  passive  congestion,  is  due  to  some  interference 
with  the  outflow  of  the  blood  from  an  organ  or  tissue.  The  obstruction  may  be 
due  to  causes  situated  in  the  heart,  mediastinum,  or  lungs,  or  to  more  strictly 
local  and  circumscribed  conditions.  A  great  variety  of  causes  might  be  men- 
tioned, such  as  the  external  compression  of  the  efferent  veins  by  tumors,  aneu- 
risms, ligatures,  inflammatory  infiltrations  and  exudates,  cicatricial  bands; 
closure  of  the  lumen  of  veins  by  ingrowing  tumors,  thrombosis,  or  embolism; 
pressure  in  the  abdominal  cavity  from  timrors,  effusions,  and  the  pregnant 
uterus;  constriction  of  the  veins  of  the  intestine  by  the  neck  of  the  sac  in  strang- 
ulated hernia. 

The  result  depends,  of  course,  upon  the  extent  of  the  obstruction,  its  site, 
and  the  presence  or  absence  of  a  collateral  vascular  sj'stem.  If  the  part  be  sup- 
plied with  anastomosing  branches,  occlusion  of  a  vein  is  followed  by  only  a  tem- 
porary overfilling  of  the  veins  on  the  distal  side  of  the  obstruction.  If,  however, 
comnumication  with  other  veins  is  slight  or  lacking,  then  more  serious  and  last- 
ing disturbance  will  arise. 

The  pathological  changes  which  result  from  the  complete  obstruction  of  the 
return  flow  through  the  veins  of  an  organ  or  tissue  have  been  fairly  well  deter- 
mined from  experiment  and  clinical  observation.  The  veins  and  capillaries  on 
the  distal  side  of  the  obfetnaction  are  greatly  distended  with  blood.  The  distinc- 
tion between  the  axial  and  peripheral  currents  in  the  veins  is  lost,  the  plasma 
gradually  disappears,  and  the  vessels  become  filled  with  closely  packed  red 
blood  corpuscles.  In  an  hour  or  two  the  blood  has  stopped  in  the  veins  and 
capillaries  (stasis),  and  a  few  red  cells  find  their  way  from  the  vessels  into  the 
neighboring  tissue  spaces.  If  there  be  any  anastomoses  with  other  vessels, 
capillaries  hitherto  unseen  open  up  and  an  attempt  is  made  at  re-establishing 
the  circulation.  The  effect  of  all  this  is  that  a  rise  of  pressure  occurs  in  the  veins 
and  capillaries,  causing  them  to  dilate.  The  blood  becomes  still  more  venous, 
owing  to  the  stasis,  and  this  interferes  with  the  vitality  of  the  endothelial  cells 


236  AiIERIC.\N  PRACTICE  OF  SURGERY. 

lining  the  vessels.  Then,  owing  to  the  distention  of  the  vessels  and  the  lowered 
nutrition  of  their  walls,  transudation  of  the  fluid  part  of  the  blood  occurs.  The 
process  is  in  part  compensated  by  contraction  of  the  arterioles  in  the  congested 
area,  which  is  secondary  to  the  diminished  amount  of  blood  flowing  through  the 
part.  This  tends  to  prevent  an  excessive  increase  m  the  intravenous  pressiu-e, 
to  limit  the  amoimt  of  transudation,  and  to  give  time  for  a  collateral  circulation 
to  be  established. 

To  gross  appearance,  a  region  the  seat  of  passive  congestion  is  swollen, 
dusky  red  or  purplish-red  m  color  (cyanosis),  cooler  than  normal,  and  its  func- 
tional activity  is  diminished. 

The  final  results  of  passive  congestion  depend  upon  the  extent  and  duration 
of  the  condition.  Temporary  congestion  may  lead  to  no  permanent  changes. 
Congestion  continued  for  a  longer  period  causes  pressui'e  upon  the  cells,  which 
become  fattily  degenerated,  hydropic,  and  atrophied.  In  the  more  advanced 
conditions  many  cells,  especially  the  more  highly  differentiated,  such  as  the 
parenchymatous  cells  of  glands,  disappear  and  are  replaced  by  fibrous  tissue. 
The  disintegration  of  the  red  corpuscles  which  have  passed  into  the  tissues  leads 
also  to  the  deposit  of  blood  pigments  (brown  induration).  In  the  most  severe 
cases,  where  the  circulation  is  absolutely  and  permanently  stopped,  hemorrhagic 
infarction  of  the  part  may  occur,  followed  by  gangrene. 

(Edema. — Mention  has  been  made  of  the  fact  that  in  passive  congestion  the 
plasma  passes  out  from  the  vessels  mto  the  interstices  of  the  tissues.  Should 
the  lymph  circulation  be  inadequate  to  carry  it  away,  it  accumulates  in  the  part 
and  leads  to  the  condition  Icnown  as  ccdema  or  dropsy.  This  transudation  and 
accumulation  of  the  fluid  portion  of  the  blood  maj-  take  place  in  various  parts 
of  the  body.  It  may  occur  in  the  peritoneal  cavity,  and  is  then  Icno'mi  as  ascites. 
Effusion  into  the  pericardial  and  pleural  cavities  is  spoken  of  as  hydropericar- 
diwn  and  hydrothora.v,  respectivel}'';  into  the  tunica  vaginalis,  as  hydrocele;  into 
the  subarachnoid  space,  as  external  hydrocephalus:  into  the  ventricles  of  the 
brain,  as  internal  hydrocephalus.  Generalized  cedema  of  the  subcutaneous  and 
intermuscular  connective  tissue  is  called  anasarca. 

(Edema  occm-s  in  the  earlier  stages  of  inflammation — hence  called  inflamma- 
tory oedema — and,  as  we  have  seen,  in  passive  congestion.  Three  factors  are  of 
importance  in  determining  the  production  of  transudation  mto  the  tissues, 
namely,  pathological  variation  in  the  blood  pressure,  alterations  in  the  composi- 
tion of  the  blood  itself,  and  changes  in  the  structure  and  function  of  the  vessel 
walls.  Whether  oedema  will  result  or  not,  in  cases  of  transudation,  depends 
entirely  on  the  ability  of  the  lymph  channels  to  cope  with  the  increased  supply 
of  fluid  in  the  tissues.  Obstruction  to  the  current  in  the  lymph  vessels  does 
not  usually  cause  oedema,  inasmuch  as  the  anastomoses  are  verj^  abundant,  and 
any  excess  of  fluid  may  be  reabsorbed  by  the  veins.  Complete  obstruction  of  all 
the  IjTiiph  vessels  of  a  part  may,  however,  lead  to  a  pure  lymphatic  oedema.    The 


DISTURBANCES  OF  NUTRITION.  237 

same  thing  is  seen  in  cases  of  obstruction  of  the  thoracic  duct  ("whether  from 
tumors  or  from  other  caxises),  which  results  in  what  is  known  as  pseudo-chyloiis 
ascites. 

Increased  pressure  within  the  arteries  does  not  give  rise  to  oedema,  provided 
that  the  return  flow  through  the  veins  be  unimpaired. 

Increased  pressure  within  the  veins,  such  as  occurs  in  passive  hypersemia,  is, 
however,  an  important  factor.  Thus,  oedema  and  effusions  into  the  various  cav- 
ities of  the  body  are  common  in  cases  of  general  passive  congestion,  the  result 
of  obstructive  valvular  disease  of  the  heart  and  of  certain  pulmonarj'  and  renal 
affections  which  interfere  with  the  circulation.  In  such  cases  the  oedema  usually 
begins  in  the  dependent  or  more  peripheral  parts,  where  we  encounter  the  in- 
fluence of  gravity  or  of  a  weak  circulation. 

Local  oedema  may  follow  local  passive  congestion,  as  in  the  production  of 
ascites  in  portal  obstruction,  or  as  the  result  of  the  pressure  of  tumors,  inflam- 
matory exudates,  splints  or  other  surgical  appliances,  on  the  veins  of  a  part. 

Increased  pressure  within  the  veins  seems  to  predispose  to  transudation,  ow- 
ing to  thinning  of  their  walls  and  the  presence  of  a  vis  a  tergo.  Probably,  also, 
long-continued  distention  and  imperfect  nutrition  lead  to  impaired  elasticity  of 
the  extravascular  tissues,  so  that  the  lymph  tends  to  accumulate.  More  than 
this,  however,  seems  to  be  necessary.  Certain  oedemas  are  met  with  in  which 
the  main  condition  appears  to  be  some  alteration  in  the  secreting  powers  of  the 
endothelial  cells  lining  the  vessels.  Such  are  the  cedemas  formerly  called  hy- 
drsemic,  and  those  due  to  the  injection  into  the  circulation  of  such  substances 
as  peptone  and  the  enzymes  of  the  various  digestive  secretions.  At  any  rate, 
sufficient  evidence  has  accumulated  to  show  that  transudation  is  not  a  mere 
question  of  pressures,  filtration,  and  osmosis.  The  secretory  activities  of  the 
cells  lining  the  vessels  must  be  taken  into  account  as  well.  This  leads  us  to  con- 
clude that  there  is  not  so  much  difference  between  the  transudates  and  inflam- 
matory exudates  as  used  to  be  thought.  The  old  view  was,  that  transudates 
passed  through  the  healthy  vessel  walls  by  a  simple  process  of  filtration  or  osmo- 
sis, while  in  the  case  of  inflammatory  exudates  there  were  serious  alterations  in 
the  vascular  walls.  This  distinction  cannot  now  be  said  to  hold  good,  except  in 
the  most  general  wa}^  The  vital  secretory  powers  of  the  vascular  endothelimn 
have  to  be  taken  into  account  in  all  cases. 

Passive  effusions  or  transudates  are  clear,  usually  colorless,  of  low  specific 
gravity  (from  1.006  to  1.012),  and  relatively  poor  Ln  albumin.  A  few  leucocytes 
and  red  corpuscles  are  usually  present,  and  also  swollen  and  fattily  degenerated 
endothelium. 

Inflammatory  exudates  are  usually  turl^id,  sometimes  mixed  with  blood, 
of  high  specific  gravity,  and  rich  in  proteids.  Spontaneous  clotting  may  take 
place.  A  relatively  larger  mmiber  of  leucocytes  is  present.  Inflammatory 
oedema  is  found  in  the  neighborhood  of  inflammatory  foci  or  may  be  caused 


238  AMERICAN  PRACTICE  OF  SURGERY. 

directly  by  the  local  action  of  various  toxic,  thermal,  and  traumatic  agencies. 
It  no  doubt  represents  the  first  stage  in  the  formation  of  inflammatory 
infiltration. 

CEdematous  tissues  and  organs  present  a  characteristic  waterlogged  appear- 
ance, owing  to  the  accumulation  of  fluid  in  the  interstices.  The  part  is  swollen, 
pits  on  pressure,  and,  if  an  incision  be  made,  clear,  watery  fluid  exudes.  On  sec- 
tion, the  tissue  is  juicy,  of  a  semitranslucent  appearance,  and  drips  watery  fluid. 
In  the  case  of  an  extremity  the  skin  is  greatly  stretched,  is  shiny,  thin,  and  may 
present  livid  scars.  In  cedema  due  to  passive  congestion  the  part  may  be  con- 
gested, at  least  in  the  earlier  stages,  but  later  becomes  ana?mic,  owing  tc  the 
pressure  of  the  fluid. 

Effusions  into  the  body  cavities  lead  to  dilatation  of  the  cavity,  with  com- 
pression of  the  viscera  contained  within,  and,  in  time,  to  thickening  of  the  serous 
lining. 

Microscopically,  cedematous  tissues  present  some  enlargement,  with  more  or 
less  dissociation  of  their  elements.  In  the  more  extreme  forms  the  cells  and 
fibres  are  swollen,  hydropic,  and  vacuolated. 

The  results  of  oedema  depend  upon  its  localization  and  extent.  Effusions 
into  the  body  cavities  may  lead  to  serious  consequences,  owing  to  pressure  upon 
or  dislocation  of  important  organs.  Transudation  into  the  brain  substance,  or 
its  ventricles,  or  into  the  subarachnoid  space  may  lead  to  paralysis  and  death. 
(Edema  of  the  glottis  is  a  dangerous  and  often  fatal  complication  of  certain 
affections,  such  as  Bright's  disease,  laryngitis,  cervical  cellulitis.  Prolonged 
ojdema  of  the  skin  and  subcutaneous  tissues  leads  to  lowered  vitality  of  the  part, 
and  may  result  in  ulceration  or  gangrene.  Infection  readily  occurs,  and  the  con- 
dition may  be  complicated  by  erysipelas  or  cellulitis. 

Anaemia. — The  term  "anajmia"  literally  means  absence  of  blood.  To  a  cer- 
tain extent  the  term  as  ordinarily  used  is  a  misnomer,  inasmuch  as  complete 
absence  of  blood  does  not  occur  in  the  animal  organism,  except  in  the  most  cir- 
cumscribed areas.  Further,  we  speak  of  a  person  as  being  "auEemic,"  when  we 
mean  that  his  skin  and  mucous  membranes  are  pale  and  apparently  bloodless. 
This  pallor,  however,  need  not  depend  on  a  complete  or  partial  deficiency  in  the 
amount  of  blood  in  the  part,  but  may  be  due  to  changes  in  the  blood  itself.  The 
blood  may  be  there  in  normal  quantitj',  but  may  be  lacking  in  red  corpuscles  or 
the  corpuscles  may  be  poor  in  haemoglobin.  It  would,  therefore,  be  more  strictly 
correct  to  speak  of  a  diminution  in  the  total  quantity  of  blood  in  the  body  as 
"ischsemia,"  and  to  keep  the  term  "angemia"  for  the  purely  local  disturbances 
associated  with  deprivation  of  the  blood  supply,  to  a  part.  Alterations  in  the 
quality  of  the  blood  should  be  given  other  designations.  Probably,  however, 
the  word  "anemia"  has  been  so  long  employed  in  this  loose  way  that  it  will 
continue  so  to  be  used.  It  is  well,  however,  to  qualify  it  when  necessary,  so  as  to 
promote  precision  of  language. 


DISTURBANCES  OF  NUTRITION.  239 

General  systemic  ischiemia  will  be  discussed  elsewhere,  and  we  will  confine 
our  remarks  here  to  the  consideration  of  loca,l  ana?mia  and  ischa^mia. 

The  supply  of  blood  going  to  a  part  may  be  diminished  or  cut  off  completely 
in  a  variety  of  ways.  The  total  quantity  of  blood  in  the  body  may  be  less  than 
normal,  so  that  a  smaller  quantity  reaches  the  various  parts ;  or  some  local  con- 
dition may  prevent  the  blood  reaching  the  part.  Thus,  the  lumina  of  the  afferent 
arteries,  arterioles,  and  arterial  capillaries  may  be  diminished  or  occluded  by 
pressure  from  without,  spasm,  or  alterations  in  the  structure  of  their  walls. 
Local  anisemia,  for  example,  may  be  produced  by  the  compression  of  an  extrem- 
ity by  an  Esmarch  bandage,  the  ligation  of  the  principal  arteries,  the  pressure 
of  a  tumor,  of  an  inflammatory  exudate  or  effusion,  or  of  a  contracting,  cica- 
tricial band.  The  artery  may  also  be  more  or  less  completely  occluded  by  end- 
arteritis, sclerosis,  or  the  invasion  of  malignant  growths;  or  its  lumen  may  be 
obstructed  by  thrombi  or  emboli.  Disturbances  of  the  vasomotor  system  may 
produce  local  ischsemia.  Brown-Sequard  showed  that  stimulation  of  the  cervical 
sympathetic  is  followed  by  contraction  of  the  arterioles  of  the  same  side  of  the 
head.  An  excess  of  blood  in  any  part,  as  in  some  cases  of  passive  congestion, 
may  result  in  a  deficiency  of  blood  in  some  other  region.  This  is  called  collateral 
ancemia.  A  good  example  of  this  is  seen  in  the  ordinary  "faint."  Under  the 
influence  of  pain,  emotion,  or  fright,  a  nervous  disturbance  takes  place,  which 
determines  large  quantities  of  blood  to  the  abdominal  viscera.  This  leads  to 
ischaemia  of  the  brain  and  loss  of  consciousness. 

In  certain  parts  of  the  body,  such  as  the  heart,  brain,  spleen,  kidneys,  some 
portions  of  the  long  bones,  and  the  retina,  there  are  what  are  known  as  "  ter- 
minal" or  ''end"  arteries;  that  is  to  say,  arteries  which  do  not  connect  with 
anastomosing  branches.  Should  such  an  end  artery  be  occluded,  complete  anae- 
mia of  the  part  ordinarily  supplied  by  that  vessel  will  result.  This  leads  to  the 
so-called  ancemic  necrosis  or  infarction.  The  condition  is  met  with  typically  in 
the  kidney,  where  we  find  more  or  less  wedge-shaped  areas  of  an  opaque,  yellow- 
ish color,  devoid  of  blood,  and  showing  microscopically  coagulation-necrosis.  At 
the  apex  of  the  wedge  can  be  demonstrated  the  occluded  vessel.  Such  an  infarct 
is  called  an  ancemic  or  white  infarct.  Blood  may,  however,  make  its  way  in  time 
from  the  neighboring  capillaries  into  the  anfemic  part,  thus  converting  the  white 
into  a  red  or  hemorrhagic  infarct.  In  the  case  of  the  brain,  infarction  is  followed 
by  colliquative  necrosis  (red  or  yellow  softening).  Infarcts  are  most  commonly 
produced  by  emboli.  If  infection  take  place,  we  get  suppuration  in  the  affected 
part.  If  the  affected  part  remain  aseptic  and  if  it  be  not  of  vital  importance, 
the  dead  tissue  is  in  time  absorbed  and  replaced  by  fibrous  tissue. 

The  results  of  a  circumscribed  anaemia  depend  upon  its  extent  and  upon  the 
locality  which  it  occupies.  Complete  deprivation  of  the  blood  supply  in  certain 
areas  produces,  as  we  have  seen,  death  of  the  part.  In  other  regions,  where  a 
collateral  circulation  is  present  or  can  be  established,  less  disturbance  is  mani- 


240  M'lERICAN  PRACTICE  OF  SURGERY. 

fested.  Provided  that  the  circulation  be  cut  off  for  only  a  short  time,  no  lasting 
results  follow.  More  severe  distiu-bance  may  result  in  minor  degenerative 
changes  and  atrophy  of  the  cells  of  the  affected  part.  Where  large  vessels  are 
obstructed  it  is  not  uncommon  to  find  new  channels  of  supply  opened  up,  and 
previously  existing  anastomosing  branches  enlarge  and  dilate  to  meet  the  altered 
conditions  of  nutrition. 

ALTERATIONS   OF  THE   BLOOD. 

These  are  chiefly  of  interest  to  the  physician.  They  will,  therefore,  be  dealt 
with  here  only  in  a  sketchy  way,  but  an  attempt  will  be  made  to  indicate,  as  far 
as  may  be,  the  bearing  of  disorders  of  the  blood  on  surgical  practice 

In  brief,  the  blood  consists  of  a  fluid  part — the  plasma — and  certain  formed 
elements — the  red  corpuscles,  leucocytes,  haematoblasts  or  blood  platelets  and 
" haemokonien "  or  "dust  bodies." 

The  blood  may  manifest  abnormal  changes  in  regard  to  its  total  quanti  y. 
It  may  be  excessive  in  amount  (plethora)  or  diminished  (ischcemia,  oligmnia) ;  or 
the  relative  proportions  of  plasma  and  corpuscles  may  be  altered.  Thus,  there 
may  be  an  absolute  or  relative  increase  in  the  plasma,  while  the  corpuscles  are 
normal  in  numbers  and  character  (hydrcemia) ;  or,  again,  the  plasma  may  be  di- 
minished in  amount,  so  that  the  blood  becomes  more  concentrated  (polyqjthwmia). 

Foreign  substances  may  gain  entrance  into  the  blood,  or  substances  which 
are  normally  present  in  small  amovmt  may  be  abnormally  increased.  Thus,  bile, 
melanin,  coal  pigment,  calcareous  salts,  fat,  sugar,  glycogen,  toxic  substances  of 
many  kinds,  portions  of  tmnors,  necrotic  tissue,  gas,  bacteria,  and  animal  para- 
sites may  be  foimd  in  the  blood. 

Finally,  the  corpuscles  may  be  altered  in  number,  both  absolutely  and  rela- 
tively to  the  amount  of  plasma,  or  they  may  vary  in  their  relative  percentage  to 
one  another,  or,  again,  in  their  quality  and  characteristics.  The  red  cells  may 
be  diminished  in  numbers,  as  in  most  forms  of  anaemia,  or  increased.  They 
may  be  deficient  in  hsemoglobin,  as  in  chlorosis,  or  certain  of  them  may  contain 
an  excess  of  this  substance,  as  in  pernicious  ansemia.  The  leucocytes  may  be 
increased  (leucocytosis) ,  or  diminished  (leucopenia) ,  in  numbers;  they  may  be 
altered  in  the  proportions  which  one  form  bears  to  the  other;  or,  finally,  certain 
abnormal  forms  ma}^  make  their  appearance,  as  in  leukaemia. 

By  an  extension  of  the  idea,  the  term  "anaemia"  is  commonly  employed  to 
designate  changes  in  the  number  and  character  of  the  corpuscles,  as  well  as 
diminution  in  the  total  amoimt  of  blood.  It  is  usual  to  divide  the  anaemias  into 
■primary  and  secondary.  The  primarj^  are :  chlorosis,  pernicious  anaemia,  leukae- 
mia, and  pseudo-leukaemia.  The  secondary  anaemias  result  from  a  great  variety 
of  caases,  such  as  loss  of  blood,  impaired  nutrition,  cachexia,  the  presence  of 
intest'inal  parasites,  infection,  toxaemia. 


DISTURBANCES  OF  NUTRITION.  241 

The  Primary  Anaemias.— CVi/orosis.— The  main  changes  in  the  blood  are  as 
follows :  The  specific  gravity  is  reduced.  The  number  of  the  red  cells  is  normal 
or  nearly  so.  In  neglected  cases  they  may,  however,  sink  to  1,500,000  per  cubic 
millimetre  (Stengel).  Not  infrequently  they  are  increased  (7,100,000  in  one  of 
Cabot's  cases).  The  average  would  be  about  4,000,000  or  slightly  over  it.  The 
diagnostic  point  is  the  diminution  of  the  htemcglobin  out  of  proportion  to  the 
diminution  of  the  red  cells.  It  may  be  reduced  to  twenty  per  cent  or  xmder,  but 
on  the  average  is  about  forty-one  per  cent.  The  number  of  the  leucocytes  is 
about  normal.  Rarely,  they  are  somewhat  increased,  especially  during  rapid 
convalescence.  The  hsematoblasts  are  always  increased.  In  severe  cases  the 
red  cells  are  somewhat  diminished  in  size.  In  mild  cases  the  size  is  unaltered. 
Only  in  the  severer  forms  is  poikilocytosis  observed.  Rarely,  normoblasts  may 
be  seen. 

The  disease  is  found  almost  excmsively  m  girls  and  young  women,  develop- 
ing with  the  onset  of  puberty  or  shortly  after.  Thrombosis  of  the  cerebral  si- 
nuses and  of  the  veins  of  the  extremities  is  a  not  infrequent  complication. 

Pernicious  Anemia. — The  striking  peculiarity  in  this  disease  is  extreme  dim- 
inution in  the  number  of  the  red  cells,  with  a  relative  increase  in  the  amount  of 
the  hemoglobin.  The  red  cells  usually  fall  to  between  2,000,000  and  1,000,000 
per  cubic  millimetre.  The  lowest  count  on  record  is  in  a  case  of  Quincke's — 
143,000.  The  total  amount  of  htemoglobm  is,  of  course,  much  below  the  normal, 
but  is  relatively  increased  per  corpuscle.  The  color  index  may  reach  as  high  as 
1.7.  With  regard  to  the  size  of  the  red  cells,  the  average  diameter  is  increased, 
but  normocytes,  microcytes,  and  macrocytes  are  to  be  seen.  Usually  poikilocy- 
tosis is  marked.  The  formation  of  rouleaux  is  absent  or  slight.  The  blood  clots 
slowly.  Basophilic  degeneration  may  sometimes  be  seen  in  the  red  corpuscles. 
Nucleated  red  cells,  normoblasts,  and  megaloblasts  are  usually  to  be  found  in 
considerable  numbers. 

The  leucocytes  are  usually  greatly  diminished  in  severe  cases.  There  is  a 
relative  increase  in  the  lymphocytes.  Rare  myelocytes  may  be  met  with.  The 
blood  platelets  are  diminished. 

Leukcemia. — The  most  important  of  the  primary  ansemias,  from  the  surgeon's 
point  of  view,  is  leukemia.  This  disease  is  manifested  in  two  well-marked  forms, 
the  lymphatic  and  the  myelocytic.  According  to  the  predominating  type — for 
mixed  forms  are  not  uncommon — the  most  striking  external  featvues  are  en- 
largem.ent  of  the  lymph  nodes,  enlargement  of  the  spleen,  and  pain  in  the 
bones.  For  the  relief  of  these  conditions  the  surgeon  is  occasionally  consulted, 
and,  if  unwary,  may  be  led  seriously  astray,  to  the  great  detriment  of  the  patient. 
A  careful  blood  examination  is  called  for  in  all  cases  of  ansemia  associated  with 
enlargement  of  the  lymph  nodes  or  spleen,  and  will  reveal  the  true  nature  of  the 
case.  Operative  measures  are  uncalled  for  in  such  cases,  and,  in  fact,  are  very 
liable  to  end  fatally  for  the  patient. 


242  AMERICAN  PRACTICE  OF  SURGERY. 

Leuka?mia  is  characterized  by  the  appearance,  in  the  blood  and  tissues,  of 
enormous  numbers  of  leucocytes.  According  to  the  appearance  of  the  blood  and 
the  condition  of  the  organs,  we  can  differentiate  lymphatic  leuksemia,  both  acute 
and  chronic,  and  myelocytic.  Mixed  forms  also  occur.  The  cause  is  still  un- 
known, but,  whatever  it  may  be,  it  certainly  stimulates  greatly  the  formation 
and  cell  division  of  the  leucocytes,  and  increases  the  facilities  for  these  leucocytes 
to  enter  the  blood. 

Acute  lymphatic  leukamia,  or  acute  lymphocythtemia,  generally  occurs  m 
young  persons  between  the  ages  of  eleven  and  twenty-four.  It  may  rarely  be 
found  in  very  young  children,  and  has  been  observed  at  birth.  It  begins  acutely 
with  fever,  a  rapidly  progressive  antemia,  hemorrhages  from  the  mucous  mem- 
branes, purpuric  spots  upon  the  skin,  and  slight  or  moderate  enlargement  of 
the  lymph  nodes,  spleen,  and  liver.  The  affection  ends  fatally  in  five  or  six 
weeks  as  a  rule.  Rarely,  it  may  terminate  in  a  few  days.  Occasionally  it  may 
last  some  weeks  or  even  months,  and  then  becomes  chronic.  Vomiting  and 
diarrhoea  occur,  ulcerations  take  place  in  the  mouth  and  gastro-intestinal  tract, 
the  patient  becomes  rapidly  exhausted,  and  passes  into  a  "typhoid"  state,  in 
which  he  dies.    Delirium,  convulsions,  and  coma  may  be  observed. 

Chronic  lymphatic  leukcemia,  when  typical,  begins  more  gradually,  with 
local  manifestations  in  the  form  of  enlargement  of  the  various  lymph  nodes,  to 
which  general  symptoms  are  superadded  only  in  the  later  stages.  The  disease 
lasts  some  months  or  for  several  years ;  on  the  average,  from  nine  months  to  two 
years.  The  nodes  most  often  affected  are  the  cervical,  then  the  inguinal,  retro- 
peritoneal, mesenteric,  and  axillary.  Ultimately  all  become  involved.  The 
spleen  and  liver  are  moderately  enlarged.  Moderate  anemia,  emaciation,  and 
progressive  loss  of  strength  are  the  leading  features.  Later,  a  tendency  to 
hemorrhages  into  the  skin  and  viscera,  and  from  the  various  mucous  surfaces, 
manifests  itself. 

With  regard  to  the  blood,  there  is  a  marKecl  leucocytosis,  the  white  cells 
reaching  from  100,000  to  300,000  per  cubic  millimetre  in  the  chronic  form,  and 
100,000  or  less  in  the  acute.  The  leucocytosis  is  therefore  much  less  than  in  the 
myelocytic  type.  The  leucocytosis  is  further  characterized  by  the  enormous  pre- 
ponderance of  the  mononuclear  forms.  In  healthy  blood  the  lymphocytes  are 
somewhat  less  than  thirty  per  cent  of  the  total  number  of  leucocytes,  but  in 
lymphatic  leukjemia  they  may  amount  to  more  than  ninety  per  cent.  In  the 
acute  form  the  large  lymphocytes  tend  to  predominate,  while  in  the  chronic  it  is 
the  small. 

Myelocytic  Leukajnia. — This  is  the  form  of  leukfemia  most  commonly 
met  with,  and  is  the  usual  type  found  in  the  adult.  In  the  vast  majority 
of  cases  it  comes  on  gradually.  The  general  health  begins  to  fail,  the  skin 
becomes  pale  and  muddy,  there  is  a  gradually  increasing  enlargement  of  the 
abdomen,  and  possibly  a  dragging  pain  in  the  left  flank.     A  diurnal  rise  in 


DISTURBANCES  OF  NUTRITION.  243 

temperature  may  be  the  first  symptom  in  some  cases.  Priapism  may  also  be  an 
early  sign. 

Myelocytic  leukaemia  is,  as  a  rule,  a  chronic  affection.  Rarely  it  begins 
acutely  with  fever  and  hemorrhages.    The  result  is  invariably  death. 

The  symptoms  are  at  first  slight,  and  patients  usually  seek  medical  aid  some 
time  after  the  disease  has  become  well  established.  A  sense  of  weight  or  actual 
pain  in  the  abdomen,  due  to  the  enlarged  spleen,  is  sometimes  complained  of, 
and  the  patient  may  himself  discover  the  existence  of  a  tumor  in  the  abdomen. 
The  progressive  enlargement  of  the  spleen  is  the  most  constant  and  conspicuous 
feature  of  the  disease,  and  is  often  associated  with  enlargement  of  the  liver.  In 
such  cases  the  protuberant  abdomen  contrasts  greatly  with  the  emaciation  of  the 
thorax.  The  various  lymph  nodes  are  usually  slightly  enlarged,  but  not  ob- 
trusively so.  Tenderness  over  the  bones  is  experienced  in  some  cases.  The  skin 
and  mucous  membrane  are  somewhat  pale  and  earthy  in  appearance,  but  the 
outward  evidences  of  anaemia  need  not  be  striking.  There  are  general  lassitude 
and  weakness,  and  there  may  be  dyspnoea,  palpitation  of  the  heart,  and  faint- 
ness  on  exertion.  The  patient  gradually  emaciates,  and  there  are  occasional 
elevations  of  body- temperature.  The  average  duration  of  the  disease  is  from 
one  to  three  years. 

A  rare  form  of  myelocytic  leukaemia,  but  one  which  undoubtedly  occurs,  is 
the  so-called  myelogenous.,  in  which  the  spleen,  lymph  nodes,  and  liver  are 
not  enlarged,  at  least  to  physical  examination,  the  characteristic  changes  of  the 
disease  being  confined  to  the  bone-marrow.  The  blood  changes  are,  however, 
identical  with  those  of  the  ordinary,  or  spleno-myelogenous,  form. 

The  blood  in  myelocytic  leukaemia  shows  a  diminution  in  the  red  cells  and  a 
great  increase  in  the  white.  The  hajmoglobin  content  of  the  blood  is  diminished. 
The  red  cells  usually  average  about  3,000,000  per  cubic  millimetre,  but  may  be 
reduced  to  1,000,000  or  less.  Ordinarily  the  white  cells  exceed  in  number  100,000 
per  cubic  millimetre,  and  may  reach  1 ,000,000  or  even  more.  Cases  have  been 
known  where  the  white  cells  were  as  numerous  as  the  red. 

The  character  of  the  white  cells  present  in  the  blood  is  the  most  important 
diagnostic  feature  of  this  disease.  Not  only  are  the  ordinary  leucocytes  in- 
creased in  numbers,  but  certain  abnormal  forms,  chiefly  derived  from  the  bone- 
marrow,  make  their  appearance  in  great  abundance.  Three  types  of  myelo- 
cytes, one  or  other  of  which  may  predominate,  are  to  be  found — the  eosinophilic 
marrow  cell,  the  neutrophilic  marrow  cell  (Ehrlich's  Markzelle),  and  the  marrow 
cell  of  Cornil.  Occasionally  cells  with  coarse  basophilic  granulations  may  be 
found  (Mastzellen).  All  the  forms  just  mentioned  are  mononuclear.  Dwarfed 
forms  of  the  various  white  cells  are  often  to  be  found.  The  red  cells  usually 
show  all  the  changes  peculiar  to  a  severe  primary  anaemia.  Nucleated  forms, 
generally  normoblasts,  but  also  megaloblasts,  may  be  noted.  Basophilic  degen- 
eration also  occurs,  and  sometimes  there  is  poikilocytosis. 


244  AMERICAN  PRACTICE  OF  SURGERY. 

It  is  important  to  remember  that  an  intercurrent  inflammatory  process  may 
greatly  modify  tlie  blood  picture  of  leukaemia.  In  such  cases  the  tendency  is  for 
the  blood  to  approximate  to  the  type  of  the  ordinary  febrile  leucocytosis.  The 
total  number  of  leucocytes  is  diminished,  and  the  ordinary  pol3'morphonuclears 
begin  to  predominate.  Nucleated  red  cells  and  myelocytes  are,  however,  never 
entirely  absent.  Under  the  continued  use  of  arsenic,  too,  there  may  be  at  times 
a  similar  reduction  in  the  number  of  the  white  cells,  and  the  blood  picture  may 
change  to  one  closely  resembling  primary  pernicious  anaemia.  Such  remissions, 
if  such  they  may  be  called,  are  but  temporary. 

The  cause  of  leukaemia  is  as  yet  unknown.  Opinions  are  also  divided  as  to 
whether  the  disease  is  allied  to  the  malignant  tumors  or  is  to  be  regarded  as  a 
specific  infectious  leucocytosis.  The  enlargement  of  the  spleen  is  not  an  essen- 
tial feature  of  the  disorder,  nor  is  this  organ  primaril}'  at  fault.  Therefore  re- 
moval of  the  spleen,  as  has  been  advocated  and  practised,  is  unscientific  and 
imjustifiable.    The  operation  is,  moreover,  usually  fatal. 

Pseudo-leiikcEmia,  or  Hodgkin's  disease,  occasionally  comes  under  the  obser- 
vation of  the  surgeon,  with  a  view  to  possible  operative  interference.  To  exter- 
nal appearance  this  disease  is  practically  identical  with  chronic  lymphatic  leu- 
kaemia, but  the  characteristic  blood  changes  of  the  latter  affection  are  not  present. 
In  Hodgkin's  disease  there  may  be  a  polymorphonuclear  leucocytosis  or  even  a 
slight  lymphocytosis.  Extreme  lymphocytosis  is  not  observed.  Inasmuch  as 
patients  suffering  from  Hodgkin's  disease  occasionally  develop  leukaemia,  there 
is  some  reason  for  thinking  that  leukaemia  and  pseudo-leukaemia  are  simply 
phases  of  one  and  the  same  pathological  process.  The  surgeon  may  be  called 
upon,  in  Hodgkin's  disease,  to  remove  nodes  which  are  pressing  upon  important 
structures. 

The  Secondary  Anaemias. — Besides  the  grave  forms  of  anaemia  just  referred 
to  there  are  others,  less  severe  and  often  temporary,  which  result  from  affections 
other  than  those  of  the  blood  itself  or  blood-forming  organs.  The  causes  are 
very  varied.  Chief  among  them  are  hemorrhage,  malignant  disease,  chronic 
suppm'ation,  acute  and  chronic  infectious  diseases,  nephritis,  dj'sentery,  heart 
disease,  tox£en:ia  of  all  kinds,  prolonged  lactation,  myxoedema,  rickets,  Addi- 
son's disease,  and  any  condition  which  leads  to  disintegration  of  the  blood  cells. 

In  general,  it  may  be  said  that  the  red  corpuscles  are  more  or  less  dmiinished 
in  numbers.  The  red  cells  may  be  deformed  or  of  small  size.  In  some  severe 
cases  the  blood  may  resemble  in  many  particulars  that  of  chlorosis  or  that  of 
pernicious  anaemia.  Normoblasts  occur,  but  are  scanty.  Megaloblasts  are 
encountered  still  more  rarely.     Ivaryokinesis  and  karyolysis  may  be  observed. 

Leucocytosis  may  or  may  not  be  present.  The  white  cells  are  usually  in- 
creased in  number  in  cases  of  malignant  disease,  in  tuberculosis  with  ulceration, 
and  in  suppurative  processes  generally.  The  increase  is,  as  a  rule,  in  the  poly- 
morphonuclear form. 


DISTURBANCES  OF  NUTRITION.  245 

The  Ancemia  from  Hemorrhage. — The  subjective  and  objective  phenomena  of 
sudden  and  extreme  loss  of  blood  are  well  known  and  need  not  be  described  here. 
With  regard  to  the  blood  itself,  there  is,  of  course,  a  more  or  less  pronounced 
diminution  in  its  total  quantity,  involving  all  its  components.  The  red  cells  are 
diminished  in  numbers,  and  there  is  a  corresponding  reduction  in  the  amount  of 
ha}moglobin.  If  the  hemorrhage  be  recovered  from,  the  loss  in  bulk  of  the  blood 
is  compensated  by  a  reabsorption  of  plasma  from  the  interstices  of  the  tissues 
and  by  contraction  of  the  vessels.  The  blood  thus  becomes  more  watery.  The 
red  cells  are  not  altered  in  appearance.  Shortly  after  the  loss  of  blood,  a 
tendency  toward  restoration  of  the  former  condition  manifests  itself.  The  red 
cells  gradually  increase  in  numbers,  and  young  forms,  microcytes  and  macro- 
cytes,  make  their  appearance,  with  also  nucleated  forms.  The  haemoglobin  is 
not  so  quickly  replaced  as  the  cells,  so  that  many  of  them  appear  to  be  chlorotic. 
Very  shortly,  too,  after  the  occurrence  of  the  hemorrhage,  regenerative  changes 
become  strongly  marked  in  the  leucocytes,  which  are  notably  increased  in 
number.  This  post-hemorrhagic  leucocytosis  is  a  constant  and  characteristic 
feature.  The  blood  thus  gradually  becomes  more  concentrated,  and  finally  as- 
sumes its  normal  condition. 

The  length  of  time  required  for  complete  return  to  the  normal  depends  upon 
the  amoimt  of  blood  lost,  the  age  and  idiosyncrasy  of  the  patient,  the  character 
of  his  food,  medicinal  measures,  and  so  on.  Small  losses  of  blood  may  be  re- 
paired in  from  two  to  five  days;  larger  ones  may  require  a  month.  Young  chil- 
dren stand  hemorrhage  badly  and  take  longer  to  recover. 

The  blood  picture  after  repeated  small  hemorrhages  is  quite  different.  Such 
hemorrhages  may  be  the  result  of  nose-bleeding,  htemoptysis,  lijematemesis, 
melgena,  hemorrhoids,  haemophilia,  the  hemorrhagic  diathesis,  certain  uterine 
disorders,  intestinal  parasites.  Small  hemorrhages,  as  we  have  seen,  are  quickly 
compensated  and  repaired.  Should  they  be  repeated  before  restoration  to  the 
normal  can  take  place,  we  get  the  picture  of  chronic  ansemia.  The  extent  of  this 
will,  of  course,  depend  upon  the  number  of  the  hemorrhages,  their  severity,  and 
the  vitality  of  the  patient.  The  main  changes  may  be  summed  up  as  follows: 
The  red  cells  are  diminished  in  numbers  and  the  blood  becomes  more  watery; 
the  haemoglobin  is  diminished  in  proportion  to  the  diminution  of  the  red  corpus- 
cles, but  may  be  even  more  reduced  in  severe  cases;  microcytes,  macrocytes, 
and  poikilocytes  may  be  found;  nucleated  red  corpuscles  are  not  uncommon; 
the  red  cells  show  sometimes  polychromatophilism;  the  leucocytes  (usually  the 
polynuclear)  at  first  are  often  increased,  but  in  advanced  cases  may  be  dimin- 
ished. In  the  most  extreme  cases  the  blood  may  resemble  very  closely  that  of 
primary  pernicious  anaemia. 

Leucocytosis. — Leucocytosis  is  an  increase  in  the  number  of  leucocytes  pres- 
ent m  a  given  quantity  of  blood  removed  from  a  peripheral  vessel,  above  the 
number  normal  for  the  individual  concerned.    Leucocytosis  usually  concerns 


246  AMERICAN  PRACTICE  OF  SURGERY. 

the  polymorphonuclear  leucocytes,  but  the  others,  lymphocytes  and  eosmophiles, 
may  be  at  times  affected.  Therefore,  in  determining  leucocytosis  it  is  wise  to 
make  a  differential  count  of  the  forms  present. 

Leucocytosis  may  be  physiological  or  pathological. 

Physiological  leucocytosis  is  met  with  in  the  young  infant,  and  also  in 
adults  during  digestion,  during  pregnancy,  just  before  death,  after  violent 
exercise,  after  massage,  after  short  cold  baths  or  prolonged  hot  ones. 

Digestion  leucocytosis  amounts  to  an  increase  of  about  one-third  in  the  mmi- 
ber  of  the  white  cells.  The  normal  percentages  of  the  various  cells  may  remain 
the  same,  or  the  lymphocytes  may  be  absolutely  or  relatively  increased.  In 
chronic  gastric  troubles  and  gastric  cancer,  digestion  leucocytosis  may  fail  to 
occur. 

In  infancy  the  lymphocytes  are  relatively  and  absolutely  increased — a  fact 
which  should  not  be  forgotten  in  the  examination  of  those  of  tender  age. 

Pathological  leucocj^tosis  ma}-  be  due  to  hemorrhage,  inflammation,  intoxi- 
cations, infection,  or  malignant  disease,  or  to  the  exhibition  of  certain  chemical 
substances. 

Post-hemorrhagic  leucoc}- tosis  has  already  been  sufficiently  dealt  with. 

Inflammatory  leucoc3'tosis  is  met  with  in  inflammations  of  almost  all  kinds. 
Its  degree  seems  to  depend  upon  the  balance  existing  between  the  inflammatory 
process  and  the  resisting  power  of  the  patient.  The  character  of  the  infection  is 
also  important.  Leucocj^tosis  is  most  marked  in  lobar  pneumonia;  moderate  in 
most  infective  processes,  including  suppuration  due  to  pyogenic  cocci;  but  may 
be  absent,  as  in  typhoid  fever,  malaria,  influenza,  measles,  acute  miliarj^  tuber- 
culosis, leprosy.  The  occurrence  of  leucocytosis  in  a  disease  which  ordinarily 
should  present  none  maj^  at  times  be  of  value  to  the  surgeon,  in  indicating  some 
suppurative  complication.  The  increase  of  the  leucocytes  in  inflammatory  afi"ec- 
tions  is  usuallj'  in  the  poljaiuclears. 

Extensive  malignant  disease  is  associated  with  an  increase  in  the  number  of 
the  polymorphonuclear  leucocytes.  This  may  possibly  be  due  to  ulceration  and 
secondary  infection,  at  least  in  many  cases. 

Toxic  leucocytosis  is  met  with  in  poisoning  by  ptomains,  illuminating  gas, 
ether,  quinine. 

The  administration  of  drugs,  such  as  the  salicylates,  pilocarpine,  ergotin, 
the  antipyretics,  and  tuberculin,  and  the  injection  of  normal  saline,  will  raise 
the  number  of  the  white  corpuscles. 

Lymphocytosis  may  be  found  at  times  in  rickets,  syphilis,  scurvy,  malaria, 
chlorosis,  pernicious  anaemia,  malignant  disease,  and  cachexias. 

Eosinophilia,  or  increase  in  the  number  of  the  eosinophiles,  is  found  in  some 
diseases  due  to  animal  parasites,  such  as  trichinosis  and  ankylostomiasis,  and 
in  malaria;  in  osteomalacia;  in  some  cases  of  sarcoma;  in  certain  skin  diseases, 
as  pemphigus,  pellagra,  dermatitis  herpetiformis. 


DISTURBANCES  OF  NUTRITION.  247- 

ON  CERTAIN  PRODUCTS  OF  INFLAMMATION. 

Under  this  heading  we  propose  to  deal  with  the  question  of  the  origin  and 
nature  of  inflammatory  exudates,  more  especially  in  regard  to  lymph  and  pus. 

The  proper  apprehension  of  this  subject  presupposes  a  knowledge  of  the 
principles  exemplified  in  the  process  of  inflammation.  As  this  phase  of  the 
matter  has  been  thoroughly  discussed  in  article  No.  1  we  may  proceed  at  once 
to  the  consideration  of  the  question  in  hand. 

Perhaps  the  simplest  form  of  inflammatory  exudation  is  that  known  as  serous 
exudation.  Instances  of  this  are  met  with  in  the  fluid  contained  in  blisters  pro- 
duced by  cantharides  or  by  heat,  in  the  effusion  into  joints  or  hernial  sacs,  which 
have  been  injured  and  become  immediately  inflamed.  Such  effusions  are  rare 
in  inflammation,  except  in  its  mildest  form,  but  are  a  common  result  of  passive 
congestion.  As  we  have  already  seen,  there  is  no  essential  difference  in  composi- 
tion between  the  so-called  passive  effusions  or  transudates  and  inflammatory 
exudates.  The  only  practical  distinction,  and  that  a  somewhat  rough  one,  is 
that  the  latter  contain  more  cellular  elements  and  are  much  richer  in  fibrin- 
forming  substances.  The  fluid  from  a  simple  transudate  will  not  usually  clot  on 
removal  from  the  body,  while  an  inflammatory  exudate  will.  At  most,  in  pas- 
sive effusions  of  long  standing  we  may  find  a  few  flakes  of  fibrin  floating,  and 
even  here  it  is  open  to  assume  that  a  low  grade  of  inflammation  has  been  present. 
We  have  to  recognize,  therefore,  that  there  are  many  intervening  stages  between 
a  simple  serous  effusion,  the  result  of  a  passive  transudation,  and  the  cellular, 
more  fibrin-containing  exudate  characteristic  of  inflammation.  In  many  of  these 
serous  effusions,  so  long  as  the  fluid  remains  within  the  body,  clotting  does  not 
occur;  but,  as  soon  as  it  is  withdrawn,  fibrin  is  formed  in  considerable  amount. 
Again,  we  have  inflammatory  exudates,  and  these  are  the  commoner  and  more 
characteristic  ones,  which  are  so  rich  in  fibrin-forming  substances  that  when  re- 
moved from  the  body  they  clot  promptly  and  firmly,  or  they  may  even  clot 
within  the  body.  These  exudates  constitute  what  is  usually  known  as  plastic  or 
coagulable  lymph.  The  term  "lymph"  is  somewhat  unfortunate  in  this  connec- 
tion, as  it  is  apt  to  lead  to  confusion  with  the  lymph  which  flows  within  the 
lymphatic  vessels.  This,  of  course,  has  nothing  necessarily  to  do  with  inflam- 
mation. By  preflxing  the  word  "inflammatory"  we  probably  render  the  mean- 
ing sufficiently  evident,  and  long  usage  has  by  this  time  sanctioned  the  error. 

Plastic  or  Coagulable  Lymph. — This  is  the  exudation  produced  in  what  may 
be  called  "healthy"  or  "constructive"  inflammation.  It  is  in  the  main  a  fluid 
having  properties  not  unlike  the  liquor  sanguinis,  more  particularly  in  that  it 
tends  to  coagulate.  The  amount  of  fibrin-forming  substances  is,  however,  some- 
what variable,  being  at  one  time,  as  we  have  seen  in  the  so-called  serous  exu- 
dates, comparatively  trifling;  at  another,  sufficient  to  produce  a  dense,  thready, 
firm,  coagulum,  even  during  life.    The  number  of  the  contained  corpuscular  ele- 


_MS  AMERICAN  PRACTICE  OF  SITRGERY. 

ments,  or  leucocytes,  is  also  variable.  These  are  practically  absent,  or  at  least 
quite  scanty,  in  serous  exudations,  more  abundant  in  the  ordinary  inflammatory 
exudations,  so  that  in  some  cases  it  is  difficult  to  distinguish  the  exudate  from 
pus,  save  in  its  faculty  for  coagulating.  Such  IjTnph  is  met  with  on  the  surface 
of  recent  wounds,  in  the  neighborhood  of  many  inflammatory  foci,  on  abraded 
surfaces,  and  upon  mucous  and  serous  membranes.  In  the  case  of  the  serous 
cavities,  where  considerable  quantities  of  exudation  may  collect,  we  can  differ- 
entiate several  forms,  according  to  the  relative  proportions  of  the  fluid  part  and 
the  cellulo-fibrinous  material.  Thus,  if  the  exudate  be  largely  fluid,  we  speak  of 
a  serous  exudate ;  if  mixed  with  considerable  fibrin  and  more  numerous  cells,  we 
speak  of  a  sero-fibrinous  exudate;  if  mainly  fibrin  and  cells,  we  have  a  plastic  or 
fibrinous  exudate. 

Inflammatory  exudates  are  not  without  import,  and,  indeed,  subserve  many 
useful  purposes.  First,  the  passage  out  of  fluid  and  cells  through  the  vessel 
walls  lessens  the  congestion  and  diminishes  the  distention  of  the  vessels  of  the 
inflamed  part;  secondly,  the  exudate  tends  to  dilute  any  irritating  substances, 
such  as  bacterial  toxins  or  disintegrating  tissue,  which  may  be  present;  thirdly, 
it  tends  to  flush  out  the  part,  and,  by  reducing  toxic  materials  to  a  soluble  and 
labile  form,  to  promote  the  removal  of  such  irritating  substances  from  the  part 
through  the  lymphatics  and  blood-vessels ;  fourthly,  it  in  some  cases  helps  to 
limit  the  inflammatory  process;  fifthly,  in  the  case  of  uninfected  wounds  it 
forms  a  bland  and  unirritating  natural  dressing  and  tends  to  promote  adhesion 
of  inflamed  surfaces  and  hasten  the  reparative  processes;  lastly,  in  certain  cases 
it  appears  to  possess  bactericidal  properties. 

The  importance  of  coagulable  lymph  in  connection  with  the  repair  of  injuries 
can  be  well  seen  in  the  study  of  a  simple  incised  and  uninfected  wound,  such  as 
may  be  inflicted  by  the  surgeon's  knife.  The  first  effect  of  the  incision  is  to  di- 
vide the  tissues,  vessels,  nerves,  and  other  structures  of  the  part.  At  first  a  little 
blood  will  be  effused  from  the  severed  vessels.  This  soon  stops  unless  a  large  ves- 
sel be  cut  and  left  unsecured.  Now  when  the  cut  surfaces  are  brought  into  close 
and  accurate  apposition,  we  have  an  instance  of  a  reparative  inflammation  with 
the  least  possible  amomit  of  reaction.  The  divided  cells  for  the  most  part  die,  at 
least  if  their  nuclei  be  destroyed;  the  injured  vessels  retract,  close,  and  become 
thrombosed,  and  an  outpouring  of  serum  takes  place,  which  glues  the  two  sur- 
faces together  and  exudes  slightly  upon  the  surface  as  a  clear,  transparent  fluid, 
that  ultimately  dries  into  a  delicate  membrane  of  fibrin  known  as  the  "scab." 
This  effused  serum  is  an  admirable  medium  for  the  growth  and  development  of 
new  cells,  as  it  contains  all  the  necessary  pabulmn.  Leucocytes  pass  out  from 
the  vessels  into  the  injured  region  and  into  the  lymph,  so  that  in  a  few  hours 
there  may  be  a  considerable  aggregation  of  granular  cells.  Next,  by  a  process 
not  as  yet  fully  understood,  the  adjacent  capillaries  send  out  buds  from  their 
sides,  which  gradually  become  hollowed  out  and  permeable  for  blood.    These 


DISTURBANCES  OF  NUTRITION.  249 

extend  into  the  effused  lymph  until  they  meet  similar  buds  from  other  vessels, 
with  which  they  unite,  forming  loops  of  vessels.  With  them  certain  cells  also  in- 
vade the  part,  derived  to  some  extent  from  the  proliferation  of  the  pre-existing 
connective-tissue  elements  about  the  walls  of  the  vessels,  or  possibly,  as  some 
hold,  also  from  the  germination  of  the  leucocytes.  These  are  known  as  fibro- 
blasts, and  in  time  they  become  converted  into  dense,  fibrous  connective  tissue. 
Thus,  the  jelly-like  cement  substance  originall}^  present  is  transformed  by  the  proc- 
ess of  organization  into  a  firm  connecting  substance,  cicatricial  tissue,  which 
binds  the  formerly  dissevered  surfaces  together  and  to  this  extent  makes  good 
the  injury.  This  process  is  called  union  by  "first  intention."  As  a  rule,  the  more 
highly  specialized  cells,  such  as  nerve  cells  or  those  of  glands,  are  only  incom- 
pletely restored,  if  at  all,  and  the  damage  is  repaired  by  more  or  less  inert  con- 
nective tissue.  This  ultimately  contracts,  many  of  its  vessels  become  obliter- 
ated, and  we  get  a  dense,  white  scar  or  cicatrix.  Where  the  epidermis  is  severed, 
the  epithelial  cells  grow  inward  over  the  wound,  and  its  continuity  is  restored  in 
all  parts. 

In  the  case  of  an  abrasion  or  superficial  wound,  when  of  limited  extent,  the 
exuded  fluid  coagulates  upon  the  denuded  surface,  where  it  dries,  forming  a  tough, 
somewhat  flexible  crust  or  scab.  The  effused  lymph  is  gradually  organized  in  the 
way  just  described,  and  the  epidermis  grows  inward  beneath  the  scab,  which 
eventually  falls  off,  leaving  a  slightly  reddened,  smooth  surface,  that  in  course  of 
time  pales  and  becomes  scarcely  distinguishable.  This  is  known  as  healinr 
under  a  scab,  and  is  a  very  simple  and  effective  method  where  it  is  practicable.  If 
micro-organisms  be  present,  as  they  so  often  are,  healing  by  the  two  methods 
<l€scribe<;l  may  still  go  on,  provided  that  the  infecting  organisms  are  of  low 
virulence  and  of  the  non-pyogenic  variety.  Very  frequently,  however,  as  we 
shall  shortly  see,  bacteria  greatly  interfere  with  the  process  of  healing. 

A  more  severe  type  of  inflammation  is  that  met  with  in  connection  with  se- 
rous membranes,  such  as  the  peritoneum,  pleura,  and  pericardium.  Generally 
bacteria  are  at  work  in  these  cases.  If  we  take,  for  example,  a  simple  peritonitis, 
what  happens  is  this :  Bacteria  reach  the  membrane  attacked  through  the  blood 
or  lymphatic  vessels.  We  get  all  the  phenomena  of  inflammation — congestion, 
stasis,  the  passage  out  of  plasma  and  corpuscles.  The  lining  endothelium  of  the 
membrane  becomes  swollen,  and  the  cells  composing  it  desquamate  and  undergo 
hydropic  and  fatty  changes.  Next,  the  exudate  appears  upon  the  surface,  usu- 
ally at  the  points  where  the  adjacent  coils  of  intestine  come  into  contact.  At 
such  places  the  membrane  is  reddened,  swollen,  and  covered  with  yellowish- 
white  fibrin  and  a  variable  amount  of  fluid.  If  much  fluid  be  present,  it  collects 
in  small  pockets  between  the  coils  of  intestine,  in  the  flanks,  and  behind  the  liver, 
or  may  lie  free  in  the  pelvis  and  general  abdominal  cavity.  In  the  course  even 
of  a  few  hours  the  inflamed  surfaces  become  somewhat  sticky  and  tend  to  ad- 
here.   Should  the  patient  recover,  organization  of  the  lymph  takes  place  as  above 


250  AMERICAN  PRACTICE  OF  SURGERY. 

described,  with  the  development  of  new  blood-vessels  and  the  formation  of  fibrous 
bands  between  the  coils  of  intestines  or  between  the  abdominal  walls,  diaphragm, 
and  underlying  structures.  Such  adhesions  are  surgically  of  importance,  since 
in  some  cases  they  lead  to  pressure  upon  important  structures,  obstruction  of 
ducts,  dislocation  of  the  viscera,  strangulation  and  incarceration  of  the  bowel, 
and  so  on.  In  some  cases  where  the  inflammation  has  been  prolonged,  we  may 
get  firm,  dense,  whitish,  almost  cartilaginous  plaques,  surrovmded  by  more 
fibrous  adhesions  which  seriously  hamper  the  working  of  the  various  organs. 

In  superficial  inflammation  of  mucous  membranes  we  get  similar  exudates, 
but  mixed  with  mucin  and  often  with  blood.  The  reparative  powers  of  the  epi- 
thelium on  mucous  surfaces,  especially  that  of  the  intestines,  are  not  inconsider- 
able, so  that  the  restoration  of  the  normal  structure  of  the  part  is  often 
complete  or  nearly  so.  We  see,  moreover,  in  the  case  of  mucous  membranes 
especially,  the  exudation  of  a  fluid  which  clots  both  upon  the  surface  and  in  the 
interstices  of  the  inflamed  part.  With  this,  apparently  under  the  influence  of 
bacterial  toxins,  or  the  interference  with  the  circulation,  or  both,  we  get  necrosis 
of  the  superficial  part,  with  the  formation  of  what  is  known  as  a  "croupous" 
deposit  or  pseudo-7nembrane.    This  is  met  with  notably  in  diphtheria. 

We  have  hitherto  been  dealing  with  what  may  be  termed  "reparative"  or 
"constructive"  inflammation,  the  process  by  which  a  great  variety  of  simple 
injuries  are  healed,  and  which  illustrates  also  in  typical  fashion  the  vis  medicatrix 
naturce  so  often  referred  to  by  the  older  writers.  The  result  of  inflammation  may 
not,  however,  always  be  so  happy.  Owing  to  the  nature  of  the  injury,  the  influ- 
ence of  external  deleterious  factors,  or  impaired  vitality  of  the  affected  part, 
we  may  get  a  much  more  serious  train  of  symptoms,  characterized  in  the  main 
by  the  destruction  of  tissue.  Here  we  have  to  assume  some  cause  at  work  which 
interferes  with  or  interrupts  normal  local  nutritive  reaction.  The  most  striking 
instance  of  this  is  suppurative  inf.ammation,  or  pus  formation.  In  the  case  of 
healing  by  first  intention,  as  we  have  seen,  there  is  practically  no  loss  of  tissue 
substance,  or  at  least  it  is  comparatively  trifling.  In  suppuration,  while  in  the 
end  it  may  resolve  and  heal,  as  in  the  process  of  granulation  known  as  healing 
by  "second  intention,"  there  is  invariably  a  destruction  of  substance  commen- 
surate with  the  intensity  and  duration  of  the  suppurative  process. 

Instances  of  suppurative  inflammation  might  be  multiplied  almost  beyond 
number,  since  this  condition  is  one  of  the  commonest  with  which  the  surgeon  has 
to  deal.  As  we  have  seen,  the  smaller  abrasions  and  superficial  injuries  of  cer- 
tain tissues  will,  under  favorable  circumstances,  heal  with  a  minimum  of  reaction, 
as  do  aseptic  incised  wounds.  Abrasions  of  the  skin  or  mucous  surfaces — a  con- 
dition which  implies  a  loss  of  the  superficial  epithelium — are  from  their  situation 
particularly  liable  to  infection,  so  that  an  inflammatory  lesion  is  not  infrequently 
converted  into  a  suppurative  one,  if,  indeed,  it  does  not  have  that  character 
from  the  beginning.    We  see  this,  for  example,  in  abrasions  caused  by  heat, 


DISTURBANCES  OF  NUTRITION.  251 

moisture,  friction,  desiccation,  and  cracking;  in  the  rupture  of  vesicles  and  pus- 
tules, and  in  the  excoriations  from  irritating  discharges.  In  many  cases  superfi- 
cial inflammation  is  transformed  into  one  of  a  penetrating  and  destructive  nature 
(ulceration).  Suppuration  may,  again,  take  place  in  the  deeper  tissues  and  in 
parenchymatous  organs.    Here  it  may  be  diffuse  or  localized. 

Perhaps  the  simplest  form  of  suppurative  inflammation  is  to  be  found  in 
what  is  called  healing  by  "granulation"  or  "second  intention." 

If,  for  example,  we  take  the  case  of  an  open  wound,  such  as  might  be  caused 
by  the  operative  removal  of  tissue,  trauma,  gangrene,  or  similar  cause,  we  find 
that  the  process  of  healing  proceeds  in  an  orderly  way,  much  as  it  does  in  the 
case  of  healing  by  first  intention,  except  in  so  far  as  it  is  modified  by  the  physical 
conditions  existing.  If  the  loss  of  substance  be  so  great  that  the  denuded  sur- 
faces cannot  be  coapted,  or  if  there  be  some  foreign  material  present  which  pre- 
vents proper  closure,  healing  by  simple  adhesion  is  impossible  and  repair  has  to 
be  brought  about  in  a  more  indirect  and  tedious  fashion. 

The  first  manifestation  of  reaction,  after  bleeding  has  ceased,  is  the  covering 
of  the  raw  surfaces  with  plastic  lymph.  This  acts  as  a  protective  varnish,  lessens 
irritation,  and  forms  a  suitable  pabulum  for  the  growth  of  cells.  The  next  step 
is  that,  with  a  certain  amount  of  pain  and  swelling,  and  more  or  less  systemic 
disturbance,  the  jelly-like  lymph  is  transformed  into  a  reddish,  highly  vascular, 
velvety  substance — granulation  tissue — which  is  bathed  in  a  bland,  yellowish, 
creamy  fluid — pus.  The  granulation  tissue  is  the  same  as  granulation  tissue 
everywhere  else.  It  is  composed  of  aggregations  of  cells  of  embryonic  type, 
which  have  the  power  of  developing  into  fully  formed  connective  tissue,  enclos- 
ing a  network  of  capillary  loops.  Healthy  granulation  tissue  is  smooth  and  firm 
to  the  touch,  of  jelly-like  consistence,  and  of  a  more  or  less  reddish  color,  accord- 
ing to  the  amount  of  blood  it  contains.  It  bleeds  upon  the  slightest  touch,  owing 
to  the  great  number  of  delicate  vessels  which  it  contains.  It  is,  moreover,  cov- 
ered on  the  surface  with  small  elevations  of  varying  size,  containing  minute  ves- 
sels— granulations, — the  spaces  between  which  are  filled  with  pus.  The  appear- 
ance of  these  granulations  is  a  valuable  index  to  the  nature  of  the  inflammatory 
reaction.  When  the  reparative  power  is  weak,  the  granulations  are  large,  pale, 
and  translucent,  while  the  pus  is  thin  and  watery.  When  the  part  has  been  irri- 
tated, as  from  friction  or  unsuitable  applications,  the  granulations  are  small  and 
excessively  red.  Sometimes,  where  these  causes  persist,  the  granulations  may 
disappear  in  places,  leaving  grayish  points  where  they  have  died,  or  smooth 
patches  where  they  have  ceased  to  grow.  Under  certain  abnormal  conditions, 
not  well  understood,  granulations  become  exquisitely  painful,  although  ordina- 
rily they  are  not  sensitive.  Again,  wherever  from  any  cause  cicatrization  is  being 
obstructed,  the  granulations  increase  in  size  and  may  coalesce  into  a  fungous 
mass,  popularly  known  as  "proud  flesh."  We  find  this  sometimes  occurring 
about  a  seton,  a  group  of  ligatures,  a  drainage  tube,  or  in  a  wound  involving  the 


252  AMERICAN  PRACTICE  OF  SURGERY. 

sheath  of  a  tendon.  Such  redundant  granulations  are  more  pale  and  flabby  than 
are  healthy  ones.  Under  all  circumstances  the  main  feature  of  granulation  tissue 
is  its  capacity  for  assuming  a  higher  condition,  namely,  that  of  cicatricial  tissue. 
Whenever  healing  is  prevented,  the  complete  transformation  does  not  take  place, 
and  the  granulation  tissue  will  remam  indefinitely  in  statu  quo,  ready,  however, 
at  any  time  to  fulfil  its  destiny  when  circumstances  render  this  possible. 

The  purulent  exudation  in  these  cases  may  be  regarded  as  an  excretion 
from  the  vessels, — an  exudation  peculiarly  rich  in  leucocytes,  and  containing  an 
admixture  of  fibrin  and  embryonic  cells.  Its  presence  is  the  cause  of  the  heat 
and  tension  which  are  early  manifestations  in  the  injured  region,  as  well  as  of 
the  fever  and  malaise,  should  such  there  be;  for,  as  soon  as  the  exudation  begins 
to  appear  externally,  these  symptoms  begin  to  lessen. 

It  is  a  peculiarity  of  granulating  surfaces  to  adhere  if  brought  together  and 
held  in  quiet  contact,  and  this  property  is  often  taken  advantage  of  by  the  sur- 
geon to  promote  healing.  This  method  is  known  as  healing  by  "secondary 
adhesion." 

In  the  ordinary  course  of  events,  if  the  opposing  surfaces  cannot  be  entirely 
brought  into  contact,  the  granulations  go  on  increasing  in  number,  until  they 
finally  coalesce  at  the  bottom  of  the  wound,  which  is  then  gradually  filled  up. 
Coincidently  with  this,  the  granulations  are  converted  into  connective  tissue,  the 
superficial  epithelium  proliferates  and  closes  in  over  the  surface,  and  the  loss  of 
substance  is  repaired  as  far  as  may  be  by  the  formation  of  a  dense,  white  cica- 
trix, which  ultimately  contracts  and  leads  to  more  or  less  distortion  of  the  part. 

Occasionally,  this  sequence  of  events  is  interfered  with  and  the  result  is  less 
satisfactory.  If  the  loss  of  substance  be  excessive,  it  may  be  beyond  the  power 
of  the  organism  to  repair  it,  and  we  have  a  granulating  surface,  persisting  indef- 
initely without  any  effective  attempt  at  cicatrization.  A  state  of  affairs  some- 
what like  this  is  not  infrecjuently  met  with  in  the  case  of  superficial  burns  of 
great  extent,  which  do  not  close  in  until  skin-grafting  has  been  performed.  Or, 
a  granulating  wound  may  become  infected,  as  in  hospital  gangrene  and  phagc- 
daena,  the  granulations  disappear,  and  the  process  is  converted  into  one  of  ulcer- 
ation. In  some  cases  the  base  of  the  wound  dies  and  is  converted  into  what  is 
known  as  a  slough  or  moist  eschar. 

The  Nature  and  Origin  of  Pus. — Healthy  pus — pus  bomim  vel  laudabile  of 
the  older  writens — is  a  creamlike  fluid,  of  a  yellowish-white  color,  sometimes 
having  a  slightly  greenish  tint,  with  a  faintly  animal  odor,  a  salty  and  sweetish 
taste,  and  a  soapy,  unctuous  feel.  'V"\1ien  allowed  to  stand  for  some  hours,  pus 
separates  into  two  parts — a  thick  deposit  composed  of  leucocytes  (pus  corpus- 
cles), embryonic  cells,  tissue  debris,  fat  globules,  and  sometimes  fatty  acids, 
cholesterin,  or  blood;  and  a  supernatant  serous  portion,  the  liquor  puris.  The 
liquor  puris  is  a  clear,  slightly  alkaline,  albuminous  fluid,  without  solid  particles. 

Microscopically,  the  solid  constituents  of  pus  are  found  to  consist,  in  the 


DISTURBANCES  OF  NUTRITION.  253 

main,  of  leucocytes,  adult  and  immature,  some  of  which,  in  fresh  pus  at  least, 
are  healthy  and  manifest  amoeboid  movement,  while  others  are  fattily  degener- 
ated or  are  dead. 

In  all  forms  of  inflammation,  except  possibly  the  very  slightest,  constant 
features  are  the  migration  of  leucocytes  to  the  injured  part,  under  the  influence  of 
the  obscure  force  commonly  designated  positive  chemotaxis,  and  the  exudation 
of  fluid  and  cells  from  the  vessels  (diapedesis).  These  phenomena  are  in  a  meas- 
ure a  response  to  the  increased  nutritional  demands  of  the  damaged  tissues. 
The  exudate,  however,  is  very  commonly  produced  in  excess  of  the  needs  of  the 
part,  and  therefore,  if  in  the  deeper  tissues,  will  tend  to  accumulate  there ;  or  if 
nearer  the  surface,  as  in  a  granulating  woimd,  will  make  its  way  through  the 
layer  of  granulation  tissue  to  the  surface  and  be  discharged  as  purulent  exuda- 
tion. The  formation  of  healthy  pus  is  to  some  extent  an  indication  of  the  effi- 
ciency of  the  reparative  processes,  and  we  can  thus  understand  what  the  older 
surgeons  meant  by  the  term  "'laudable"  pus,  pus  being  an  almost  constant  ac- 
companiment of  every  wound  and  surgical  operation.  But,  as  Listerism  has 
abundantly  shown,  pus  formation  is  by  no  means  a  necessary  accompaniment 
of  the  repair  of  injury. 

Some  debate  has  arisen  with  regard  to  the  question  whether  the  presence  of 
bacteria  is  essential  to  the  formiation  of  pus.  Councilman  and  others  have  been 
able  to  produce  suppuration  by  the  introduction,  into  the  subcutaneous  tissues 
of  experimental  animals,  under  strict  aseptic  precautions,  of  such  substances  as 
turpentine,  croton  oil,  metallic  mercury.  Subsequent  inoculation  experiments 
showed  that  in  many  instances  pus  so  produced  was  sterile.  Some  recent  experi- 
ments of  W.  W.  Ford's,  indicating  that  healthy  tissues  and  organs  contain  bac- 
teria normally,  may  be  held,  if  accepted,  to  invalidate  this  conclusion.  For  there 
may  have  been  present,  in  pus  produced  by  injection  of  turpentine,  microbes 
which  failed  to  grow  later,  owing  to  attenuation.  However  this  may  be,  pus, 
as  met  with  by  the  clinician,  practically  always  contains  microbes,  either  dead 
or  alive.  And,  as  is  well  known,  many  bacteria,  when  injected  into  the  tissues 
under  suitable  conditions,  are  competent  to  produce  a  suppurative  inflammation. 
Such  micro-organisms  are  usually  called  pyogenic.  Among  them  are  the 
Staphylococcus  pyogenes  aureus,  commonly  found  in  acute  abscesses,  the 
Staphylococcus  pyogenes  albus,  flavus,  and  citreus,  the  Streptococcus  pyogenes. 
Bacillus  pyocyaneus,  the  gonococcus  of  Neisser,  and  the  meningococcus.  Under 
certain  circumstances  other  bacteria,  not  ordinarily  pj^ogenic,  may  produce  pus. 
Such  are  the  B.  coli,  B.  typhi,  the  pneumococcus. 

The  Varieties  of  Pus. — Healthy  or  laudable  pus  has  just  been  described. 
Sanious  pus  is  that  which  contains  blood.  Curdy  pus  contains  particles  of  fibrin 
or  cheesy  matter  floating  in  it.  Ichorous  pus  is  of  a  watery  character.  Muco-pus 
contains  mucus.  Sero-pus  is  rather  less  rich  in  corpuscles  than  is  healthy  pus. 
Blue  pus  is  pus  of  a  bluish  or  bluish-green  color,  which  is  occasionally  met  with. 


254  AMERICAN  PRACTICE  OF  SURGERY. 

This  peculiarity  is  due  to  the  presence  of  the  B.  pyocyaneus,  a  chromogenic  ba- 
cillus of  rather  low  virulence.  Red  pus  is  due,  according  to  Ferchmin,  to  a  special 
microbe,  which  is  non-motile,  has  rounded  ends,  and  produces  a  reddish  pigment 
on  nutrient  media. 

The  Forms  of  Suppuration.— Suppuration  may  be  superficial,  involving  cu- 
taneous, serous,  or  mucous  surfaces;  or  deep,  affecting  subcutaneous  structures 
or  parenchymatous  organs.  As  examples  of  the  former  we  may  take  the  sup- 
puration which  attacks  infected  wounds,  abrasions,  or  losses  of  substance,  of 
which  we  have  just  considered,  as  the  simplest  type,  healing  by  granulation  or 
by  second  intention.  In  the  case  of  the  serous  membranes,  as  in  empyema,  pyo- 
pericardium,  and  purulent  peritonitis,  the  process  is  not  dissimilar,  except  that 
"granulations"  do  not  play  so  obvious  a  part.  Under  the  influence  of  some  ir- 
ritant the  lining  endothelium  swells,  the  cells  become  cloudy  or  fatty,  and  event- 
ually are  desquamated.  Then  effusion  from  the  vessels  of  the  membrane  takes 
place,  first  into  the  interstices,  and  then  upon  the  surface,  where  it  is  deposited 
as  plastic  lymph,  rapidly  becoming  highly  corpuscular.  The  amount  of  effusion 
is  apt  to  be  large,  and  it  collects  at  the  bottom  of  the  serous  sac,  separating  the 
two  layers  of  the  membrane  and  often  compressing  the  contained  structures. 
Resolution  takes  place  in  part  by  reabsorption  of  the  exudate  into  the  vessels, 
but  in  larger  measure  by  removal  through  the  lymphatic  channels.  The  vessels 
regain  their  normal  tone,  the  exudation  disappears,  and  the  endothelium  is  re- 
generated. Adhesion  of  the  two  layers  of  the  serous  sac  is  particularly  apt  to 
occur. 

Suppuration  in  the  deeper  tissues  may  be  circumscribed  or  diffuse.  A  good 
example  of  the  former  is  the  ordinary  abscess.  An  acute  abscess  exemplifies  in  a 
typical  way  all  the  phenomena  of  a  severe  inflammation,  terminating  in  suppu- 
ration and  destruction  of  tissue.  We  have  the  classical  symptoms  of  redness, 
swelling,  heat,  and  pain,  together  with,  in  some  instances,  constitutional  disturb- 
ance, as  headache,  fever,  rapid  pulse.  The  cause  is  some  injury,  tissue  degenera- 
tion, or  infection,  which  leads  to  irritation  of  the  part.  There  result,  thereupon, 
increased  afflux  of  blood  to  the  part,  distention  of  the  vessels,  and  exudation, 
first  of  lymph  and  then  of  corpuscles.  Owing  to  the  local  disturbance,  the  in- 
creased fluid  thus  brought  to  the  part  cannot  be  successfully  disposed  of.  It 
accumulates,  causing  pressure  upon  the  neighboring  cells,  separation  of  muscu- 
lar and  connective-tissue  fibres,  rupture  of  fibres,  vessels,  and  nerve  filaments. 
The  exudation  gives  rise  to  the  swelling,  and  the  pressure  upon  the  nerve  fibres 
produces  the  pain.  Thus  in  time  the  pus  forms  a  cavity  for  itself.  If  the  process 
do  not  soon  come  to  an  end,  the  pus  generally  burrows  through  the  tissues 
along  the  lines  of  least  resistance,  and  makes  its  way  to  the  surface  of  the  body 
or  into  some  hollow  viscus.  This  event  generally  results  in  healing  by  ordinary 
granulation,  and  is  often  imitated  by  art.  According  to  clinical  observation,  the 
raison  d'etre  of  suppuration  would  appear  to  be  an  attempt  on  the  part  of  the 


DISTURBANCES  OF  NUTRITION.  255 

organism  to  get  rid  of  offending  material,  whether  dead  tissue,  foreign  bodies, 
bacteria,  or  other  irritating  substances.  The  process  in  the  so-called  "cold"  or 
chronic  abscess  is  identical,  except  that  it  is  more  sluggish.  Swelling  is  present, 
owing  to  the  exudation,  but  the  redness,  heat,  and  pain  may  be  trifling  or  absent. 

Diffuse  suppuration  is  met  with  in  the  so-called  phlegmonous  inflammations, 
erysipelas  and  cellulitis.  Here,  the  condition  is  for  a  time  at  least  progressive, 
involving  widely  connective  tissue,  fascia,  and  tendon  sheaths.  Local  oedema  is 
marked,  but  the  inflammation  does  not  tend  to  become  circumscribed,  as  in  the 
case  of  an  abscess,  while  the  systemic  manifestations  are  much  more  severe. 
General  septicopyffimia  not  infrequently  results. 

The  Results  of  Suppuration. — Suppurative  inflammation  may  heal  if  it  be 
not  extensive,  leaving  little  or  no  traces,  or,  when  more  severe,  it  will  result  in  the 
destruction  of  the  finer  structure  of  the  part,  the  elements  of  which  are  replaced 
by  connective  tissue  that  has  no  other  function  than  that  of  restoring  the  conti- 
nuity of  the  part  and  binding  it  together.  Healing  will  more  readily  take  place  if 
the  inflammation  be  well  localized  and  so  situated  that  the  external  discharge  of 
the  pus,  whether  naturally  or  by  intention,  is  possible.  Collections  of  pus  in  the 
deeper  tissues  may  be  absorbed  and  the  destroyed  part  heal  up  with  the  forma- 
tion of  a  cicatrix,  or  the  pus  may  become  inspissated  or  infiltrated  with  lime  salts. 
In  some  cases,  especially  those  of  long  standing,  where  the  pus  is  retained,  it 
leads  to  condensation  of  the  neighboring  tissues,  with  the  formation  of  a  sort  of 
fibrous  capsule,  lined  on  the  inner  surface  with  granulation  tissue — pyogenic 
membrane.  This  membrane  is  the  result  rather  than  the  cause  of  suppuration, 
as  used  to  be  held.  When  the  pus  is  deeply  seated  and  burrows  widely,  it  at- 
tempts to  make  its  way  to  the  surface  and  produces  long  tracks  of  communica- 
tion with  other  parts,  known  as  sinuses.  When  the  pus  is  discharged  upon  the 
surface  or  into  a  hollow  viscus,  we  get  a  channel  of  communication  known  as  a 
fistula.  This  is,  strictly  speaking,  a  tube  which  is  open  at  both  ends;  but  the 
term  is  ordinarily  used  to  designate  any  passage  connecting  the  suppurating 
focus  with  the  external  air.  Suppuration  within  joints  or  in  serous  sacs  fre- 
quently leads  to  adhesion  of  the  adjacent  structures,  with  partial  or  complete 
occlusion  of  the  cavity,  compression  of  important  organs,  fibrous  ankylosis,  and 
the  like.  Calcareous  deposits  are  not  infrequent,  and  even  new  bone  may  at 
times  be  formed.  Prolonged  suppuration,  as  a  remote  sequel,  not  uncommonly 
results  in  amyloid  transformation  in  the  various  viscera.  A  most  serious  result 
is  the  entrance  of  pus  with  its  contained  micro-organisms  into  the  blood,  with  a 
general  infection  of  the  system. 


PROCESSES  OF  REPAIR. 

Bij  EDWARD  II.  XICHOLS,  M.D.,  Boston,  Mass. 

After  an  injury  -n-hich  causes  a  loss  of  substance  of  anj'  of  the  tissues  of  the 
body,  a  series  of  changes  occur  about  the  injured  area  which  make  good  the  loss. 
In  most  tissues  the  loss  is  replaced  to  a  very  limited  extent  b}'  newly  formed  tis- 
sue which  completely  restores  the  integrity  of  the  origmal  tissue.  In  such  cases 
the  process  is  spoken  of  as  a  process  of  regeneration.  In  most  cases  the  destroyed 
tissue  is  replaced  by  tissue  composed  of  newly  formed  blood-vessels  and  dense 
connective  tissue,  i.e.,  by  scar.    This  process  is  spoken  of  as  a  process  of  re-pair. 

I.  REGEXERATIOX. 

Regeneration  means  the  replacement  of  lost  tissue  by  newly  formed  tissue 
\vhich  has  the  same  structure  and  function  as  the  original.  The  power  of  regen- 
eration varies  enormously  with  different  tissues  and  with  the  age  of  a  given  tis- 
sue. The  yoimger  a  tissue  is,  i.e.,  the  more  completely  the  tissue  approaches 
embryonic  tissue,  the  greater  is  its  power  of  regeneration.  If,  for  instance,  the 
tail  of  a  tadpole  be  cut  off,  it  will  be  completely  regenerated,  muscle,  cartilage, 
and  epithelium  appearmg  in  their  regular  places.  If  the  limb  of  a  frog,  however, 
be  cut  off,  the  limb  will  not  be  regenerated. 

The  less  highly  organized  an  organism,  the  greater  its  power  of  regeneration; 
e.g.,  the  unicellular  organisms  maj^  be  cut  into  several  parts  and  a  complete  or- 
ganism maj-  be  produced  from  each  portion. 

The  more  highly  complicated  a  structure  is,  the  less  is  its  power  of  regenera- 
tion. Thus,  when  large  areas  of  skin  are  destroj'ed  the  epithelial  covering  may 
be  completely  replaced  b}'  regeneration  of  epithelium;  but  the  hair  follicles  and 
.sebaceous  glands,  composed  of  epithelial  cells  with  complicated  arrangement  and 
more  highly  differentiated  fimction,  are  not  replaced.  In  the  same  way,  if  single 
cells,  e.g.,  m  the  tubules  of  the  kidnej',  are  destroyed,  thej'  are  replaced  by  a  new 
formation  of  cells  from  adjacent  cells;  but  the  destruction  of  any  considerable 
area  of  kidney  substance  is  not  complete!}'  restored  by  regeneration. 

The  more  highly  differentiated  a  tissue  is  for  special  fmrctions,  the  less  is  the 
power  of  regeneration  of  that  tissue;  e.g.,  in  complicated  glands  there  is  greater 
power  of  regeneration  in  the  ducts  of  the  glands  than  there  is  in  the  specialized 
cells  of  the  secreting  portion.  In  the  cells  of  the  highly  specialized  central  ner- 
vous system  the  power  of  regeneration  is  extremely  limited.  It  also  is  doubtful 
whether  there  is  any  power  of  regeneration  in  striated  muscle  cells. 

256 


PROCESSES  OF  REPAIR. 


257 


When  tissue  is  regenerated  to  replace  a  loss,  the  law  is  that  the  newly  formed 
tissue  is  produced  from  similar  tissue;  e.g.,  epithelium  cannot  be  reproduced 
from  connective  tissue.  The  cells  of  the  new  tissue  arise  by  division  of  the  old 
cells  of  similar  tissue.  This  division  of  old  cells  to  form  new  ones  is  a  compli- 
cated process,  and  is  spoken  of  as  "mitosis,"  "karyokinesis,"  or  "indirect  cell 
division."  (See  Fig.  74.)  The  living  cell  consists  of  a  nucleus,  surrounded  by  a 
nuclear  membrane,  and  of  protoplasm.  In  the  nucleus  are  fluid  and  a  mesh- 
work  of  threads,  or  chromatin.  In  the  protoplasm,  alongside  of  the  nucleus,  is  a 
small  body,  known  as  the  centrosome.  When  a  cell  is  about  to  divide,  the 
centrosome  first  divides,  and  the  bodies  which  are  thus  formed  become  arranged 
at  the  opposite  poles  of  the  nucleus.  About  these  "polar  bodies"  is  seen  a 
peculiar  radiate  appearance,  known  as  the  "spindle."  The  chromatin  of  the 
nucleus  then  becomes  massed  in  thick  threads,  and  this  thick  thread  then  sep- 


Fie.  74. — Mitosis  of  Cells,  from  Human  Cancer.  1,  Thickening  of  nviclear  cliromatin,  with  dis- 
appearance of  nuclear  membrane;  2,  spindle  stage,  equatorial  arrangement  of  chromatin;  3,  later 
spindle  stage,  chromatin  becoming  arranged  about  the  poles  of  the  spindle;  4,  division  of  cell.  {Or- 
iginal.) 

arates  into  fragments  to  form  loops,  which  usually  are  arranged  with  the  open 
ends  of  the  loops  directed  toward  the  periphery,  while  their  apices  are  at  the 
equator  of  the  nucleus.  These  loops  divide  longitudinally,  and  one-half  becomes 
arranged  about  each  centrosome,  thus  forming  two  "daughter  nuclei."  This 
division  of  the  nucleus  is  followed  by  a  constriction  of  the  protoplasm,  which 
divides  into  two  parts,  one  about  each  nucleus. 


Comparative  Power  of  Regeneration  of  Different  Tissues. 

The  comparative  power  of  regeneration  varies  greatly  in  different  tissues. 

1.  Epithelium,  both  of  the  skin  and  of  the  internal  organs,  has  great  power 
of  regeneration,  but  the  degree  to  which  the  epithelium  of  different  organs  can 
regenerate  varies  greatly.  In  all  cases  the  regenerated  epithelium  arises  by 
mitosis  from  similar  adjacent  epithelium. 

In  the  skin,  after  a  loss  of  surface  epithelium,  new  epithelium  grows  over  the 
denuded  surface  from  the  epithelial  cells  at  the  edge,  and  also  may  arise  in  the 
centre  of  the  denuded  area,  if  any  islands  of  epithelial  cells  are  left  in  the  base  of 
the  ulcer.    Also,  epithelial  cells  will  arise  from  bits  of  epithelium  transplanted 


258  AMERICAN  PRACTICE  OF  SURGERY. 

from  distant  parts  of  the  same  animal  or  of  anotlier  animal  of  the  same  species. 
In  human  beings  advantage  is  taken  of  this  latter  fact  in  cases  of  extensive  burns 
or  abrasions  by  transplanting  small  bits  of  epithelium  to  the  denuded  surface, 
giving  numerous  foci  from  which  new  epithelium  may  arise.  Of  recent  years  a 
better  method  has  been  employed,  the  so-called  "Thiersch  method"  of  skin 
grafting.  By  this  method  large  pieces  of  epithelium  are  taken  from  the  sound 
skin  and  transplanted  to  the  new  area,  the  pieces  being  fitted  in  such  a  way  as 
entirely  to  cover  in  the  ulcer.  The  deeper  layers  of  this  epithelium  become  ad- 
herent to  the  denuded  surface,  and  in  a  very  brief  time  the  defect  is  entirely 
closed  by  the  transplanted  epithelium  and  by  epithelium  arising  from  the  edges 
of  the  transplanted  pieces.  The  sound  area  from  which  the  epithelium  ts  re- 
moved is  also  very  quickly  covered  in  by  epithelium,  for,  since  the  entire  thick- 
ness of  epithelium  is  not  removed  in  the  transplanted  piece,  the  epithelial  cells 
which  are  left  scattered  over  a  broad  area  quickly  proliferate  and  form  new  epi- 
thelial cells  to  replace  those  which  have  been  removed. 

In  the  uterus  there  is  marked  destruction  of  uterine  lining  epithelium  at  the 
time  of  menstruation  and  pregnancy,  but  the  cells  are  very  rapidly  reproduced 
from  the  epithelial  cells  of  the  uterine  glands.  The  same  thing  happens  after 
very  extensive  removal  of  uterine  epithelium  by  curetting. 

In  the  intestine  the  epithelium  has  great  power  of  regeneration.  An  ulcer  of 
the  intestine,  as  in  typhoid,  is  rapidly  covered  m  by  epithelium  growing  in  from 
the  sides,  and  even  imperfect  crypts  of  Lieberkiihn  are  produced,  although  villi 
are  not  formed.  In  woimds  of  the  intestine  the  inturned  edges  ulcerate,  and  are 
rapidly  covered  over  by  epithelium  in  the  same  way,  so  that  in  a  very  short  time 
(two  or  three  weeks)  it  may  be  impossible  to  detect  the  line  of  the  wound. 

Liver  epithelium  has  considerable  power  of  regeneration.  It  has  been  shown 
by  Ponfick  that  large  areas  of  the  liver  of  animals  may  be  removed  and  a  new 
formation  of  liver  substance  may  take  place.  When  small  areas  of  liver  epithe- 
lium are  destroyed,  the  lost  cells  may  be  replaced  by  a  new  formation  of  cells  at 
the  periphery  of  the  lobule — i.e.,  through  proliferation  not  only  of  the  cells  ad- 
jacent to  those  lost,  but  even  of  those  at  a  considerable  distance. 

Kidney  epithelium  has  a  very  limited  power  of  repair.  If  single  cells  of  the 
kidney  tubules  are  destroyed,  they  are  replaced  by  proliferation  of  adjacent 
epithelial  cells;  but  if  any  considerable  amount  of  renal  tissue  is  destroyed,  to 
supply  which  new  renal  tubules  must  be  formed,  the  lost  epithelium  is  not 
regenerated,  but  only  scar  tissue  is  produced.  Destroyed  glomeruli  are  not 
reproduced. 

2.  Mesenchymal  tissues.  In  tissues  of  mesenchymal  origin,  connective  tis- 
sue, cartilage,  bone,  etc.,  lost  tissue  is  replaced  by  tissue  similar  to  that  de- 
stroyed. But  in  these  closely  allied  tissues  a  certain  amount  of  exchange  of 
function  may  take  place  after  a  loss  of  tissue;  e.g.,  a  loss  of  substance  in  carti- 
lage, which  has  a  very  limited  power  of  regeneration,  is  usually  replaced  by  con- 


PROCESSES  OF  REPAIR.  259 

nective  tissue,  although  in  time  this  connective  tissue  may  be  converted  into 
cartilage  and  complete  regeneration  take  place. 

In  bone,  after  a  loss  of  tissue,  e.g.,  after  a  fracture,  there  may  be  a  new  forma- 
tion of  tissue,  which  may  in  the  course  of  time  lead  to  complete  regeneration  of 
the  bone.  This  theoretically  possible  regeneration  is  but  seldom  seen  to  any 
great  extent  in  human  fractures. 

In  muscle,  after  a  loss  of  substance,  e.g.,  after  section  or  rupture,  the  musc.e 
fibres  do  not  regenerate,  although  peculiar  changes  take  place  in  the  cut  muscle 
ends  which  have  been  described  as  regeneration,  but  which  really  represent  de- 
generative changes.  The  resulting  defect  in  muscle  is  filled  by  a  new  formation 
of  scar  tissue  derived  from  the  connective  tissue  of  the  muscle  sheaths. 


II.  REPAIR. 
Geneeal  Remarks. 

By  repair  of  a  tissue  is  meant  the  process  by  which  an  injury  to,  or  a  loss  of 
substance  of,  the  tissue  is  made  good.  This,  however,  does  not  imply  that  the 
lost  tissue  is  replaced  by  tissue  exactly  of  the  same  character,  or  with  the  same 
function  as  that  of  the  original  tissue.  In  fact,  so  far  as  the  surgeon  is  concerned, 
as  a  rule  the  loss  in  specialized  tissues  is  replaced  entirely  by  connective  tissue, 
arismg  from  pre-existing  connective  tissue,  which  finally  becomes  dense  connec- 
tive tissue  or  scar. 

Resolution. — As  has  ^een  stiown  in  the  article  on  inflammation  (q.v.),  after 
any  injury  to  any  tissue  of  the  body  there  occur  a  series  of  changes  in  the  tissues 
about  the  injured  point,  confined  at  first  almost  entirely  to  the  blood-vessels  of 
the  adjacent  tissues.  As  a  result  of  these  changes  there  is  an  escape  of  the  con- 
tents of  the  blood-vessels,  i.e.,  serum,  leucocytes,  and  red  blood  corpuscles,  with 
a  formation  of  fibrin  from  the  serum,  so  that  the  tissues  about  the  injured  area 
are  infiltrated  with  the  material  which  has  escaped  from  the  vessels,  i.e.,  the  tis- 
sues about  the  injured  area  are  filled  with  an  "inflammatory  exudate."  In  cer- 
tain cases,  usually  when  the  injury  has  been  a  slight  one  and  the  amount  of 
exudation  is  small,  the  exudation  may  be  removed  with  no  further  changes  in 
the  tissues,  and  the  function  of  the  tissues  is  renewed.  This  simple  process  is 
spoken  of  as  resolution. 

Removal  of  Exudation. — The  exudation  lies  in  the  interstices  of  the  tissues, 
and  consists  of  serum,  leucocytes,  and  fibrin,  with  perhaps  red  blood  corpuscles. 
The  fluid  serum  is  carried  off  chiefly  through  the  lymphatic  vessels,  as  is  shown 
by  the  fact  that  the  lymphatics  surrounding  such  an  area  are  dilated  in  micro- 
scopic sections;  and  if  the  injury  is  produced  in  an  extremity,  the  l3Tnphatics 
leading  from  the  limbs  show  an  increased  flow  of  lymph.  Some  of  the  serum 
may,  however,  be  taken  up  directly  by  the  blood-vessels. 


260  AMERICAN  PRACTICE  OF  SURGERY. 

The  leucocytes  in  the  exudation  also  are  partly  removed  by  i5^mphatic  ves- 
sels or  by  blood-vessels,  but  a  large  proportion  are  destroyed  by  newly  formed 
endothelial  cells,  which  arise  chiefly  by  mitosis  of  the  endothelial  cells  of  the 
lymph  spaces  in  the  vicinity  of  the  mjured  area.  These  newly  formed  cells  take 
up  and  include  the  leucocytes,  and  destroy  them  by  a  kind  of  digestion.  This 
process  is  called  phagocytosis.  If  the  exudation  contains  a  large  proportion  of 
leucocytes,  i.e.,  if  the  exudation  is  a  purulent  one,  the  removal  of  the  leucocytes 
is  more  difficult.  In  some  cases  the  fluid  portion  of  the  exudate  is  removed  by 
the  blood-vessels,  while  the  remaining  mass  of  leucocytes  undergo  fatty  degen- 
eration and  necrosis,  and  are  converted  into  a  soft,  greasy  mass,  which  m.ay  be 
surrounded  by  a  layer  of  dense  scar  tissue,  thus  being  encapsulated.  Such  a 
mass  may  persist  in  the  tissues  for  a  long  time.  In  some  cases  lime  salts  may 
be  deposited  in  such  an  area,  which  thus  becomes  gritty,  or  even  may  become 
completely  calcified,  and  may  persist  as  a  calcified  foreign  body  for  a  long  period. 

More  commonly,  in  purulent  exudations  which  lie  near  the  surface  of  the 
body,  or  near  hollow  viscera,  the  process  of  exudation  continues  imtil  the  tissues 
which  surroimd  the  purulent  exudate  become  necrotic  and  soften,  and  finally 
the  surface  is  reached  and  the  exudation  is  spontaneously  evacuated  upon  the 
surface,  or  into  a  hollow  viscus.  In  this  way  most  of  the  leucocytes  are  evacu- 
ated. In  the  surgical  treatment  of  purulent  exudations  (abscesses),  the  surgeon 
expedites  the  removal  of  leucocytes  by  making  artificial  openings  with  the  knife. 
In  this  way  much  destruction  of  tissue  is  avoided,  and  in  many  cases  the  opening 
is  better  placed  to  allow  complete  removal  of  the  exudate. 

Fibrin,  when  in  small  amounts  in  the  tissues,  undergoes  certain  changes, 
swelling  up  and  softening  and  undergoing  a  sort  of  digestion  in  the  fluids,  and 
then  being  absorbed  by  the  lymphatics.  At  times,  when  fibrin  forms  large 
masses  in  the  tissues,  it  may  be  partly  removed  by  phagocytic  action  of  giant 
cells.  When  fibrin  forms  on  surfaces  connected  with  the  outside  of  the  body,  it 
may  be  removed  in  considerable  masses  or  as  plugs  or  casts.  An  open  ulcer  may 
be  covered  by  a  crust  or  scab,  largely  fibrinous,  which  finally  is  separated  by  the 
growth  of  epidermis  beneath  it.  In  pneumonia  much  of  the  fibrin  is  expecto- 
rated as  fibrinous  plugs.  "Wlien  fibrin  forms  upon  a  surface  which  is  not  con- 
nected with  the  surface  of  the  body,  as  in  the  pleural  cavity  or  on  the  surface  of 
the  peritoneum,  it  is  replaced  by  granulation  tissue,  composed  of  newly  formed 
connective  tissue  and  new  blood-vessels,  which  grows  into,  softens  down,  and 
removes  the  fibrin.  This  granulation  tissue  becomes  dense  scar  tissue  finally, 
and  thus  produces  thickening  of  the  surface  on  which  the  fibrinous  exudate 
appeared;  or,  if  the  fibrin  was  on  two  adjacent  surfaces,  there  will  result  ad- 
hesions composed  of  dense  scar  tissue. 

The  red  blood  corpuscles  of  the  exudation,  if  present  in  small  amounts,  may 
be  carried  off  in  the  lymphatic  vessels.  If  they  are  present  in  great  quantity 
some  of  the  corpuscles  remain  in  the  tissues,  and  in  that  case  the  haemoglobin  of 


PROCESSES   OF  REPAIR.  261 

the  corpuscles  becomes  dissolved  out  and  forms  pigments  which  produce  the 
color  seen  in  the  "  black-and-blue "  spots.  The  framework  of  the  corpuscles 
finally  is  dissolved  in  the  fluids  of  the  tissue,  while  the  pigment  is  taken  up  by 
phagocytic  cells. 

Repair. — As  has  been  stated  already,  after  any  injury  of  any  tissue  of  the 
body,  of  such  a  nature  as  to  cause  a  destruction  of  tissue,  the  injury  is  imme- 
diately followed  by  changes  confined  to  the  blood-vessels — changes  which  lead 
to  the  formation  of  an  inflammatory  exudation.  Within  a  very  short  time, 
twenty-four  hours  at  most,  further  changes  occur,  both  in  the  cells  of  the  tissues 
and  in  the  blood-vessels  surrounding  the  point  of  injury,  which  lead  to  the  for- 
mation of  new  tissue  to  replace  the  lost  tissue.  In  these  changes  new  cells  are 
formed  by  mitosis  of  adjacent  cells,  and  new  blood-vessels  are  formed  by  out- 
growths from  adjacent  blood-vessels.  This  formation  of  new  cells  and  new 
blood-vessels  to  replace  destroyed  tissue  is  described  as  the  process  of  repair. 
The  process  of  exudation  and  the  process  of  repair,  however,  are  not  sharply 
separated,  as  the  exudation  persists  for  some  time  after  the  process  of  repair 
has  begim.  Ultimately,  the  exudation  disappears  and  is  replaced  by  new  cells 
and  blood-vessels,  but  for  a  considerable  time  inflammatory  exudation  and  cells 
and  vessels  exist  together.  After  the  exudation  disappears,  the  newly  formed 
tissue  undergoes  a  series  of  changes  which  convert  the  cellular  vascular  tissue 
into  a  dense  scar. 

Processes  of  Repair  in  Different  Tissues  and  Organs  of  the  Body. 
A.  Repair  of  Wounds  in  Soft  Tissues. 

In  every  wound  of  the  soft  tissues  the  immediate  result  of  the  injury  is  de- 
struction of  tissue.  This  destruction  of  tissue  is  immediately  followed  by  the 
appearance  of  an  inflammatory  exudation  about  the  point  of  injury.  In  wounds 
which  heal  without  becoming  infected  by  pathogenic  micro-organisms  (aseptic 
woimds)  the  amount  of  exudation  is  directly  proportionate  to  the  extent  of 
the  wound.  In  wounds  which  become  infected  with  micro-organisms  (septic 
wounds)  the  amoimt  of  the  exudate  is  dependent  upon  the  extent  of  the  wound 
and  upon  the  amount  of  injury  due  to  the  action  of  the  toxin  produced  by  the 
micro-organisms.  Within  a  few  hours  (twenty-four  hours  at  most)  after  the 
appearance  of  the  exudation,  there  begins  a  new  formation  of  cells  and  blood- 
vessels to  replace  the  lost  tissue.  The  general  steps  of  the  process  are  the  same 
whether  the  edges  of  the  wound  can  be  approximated  (incised  or  closed  wound) 
or  cannot  be  brought  together  on  account  of  extensive  destruction  of  tissue 
(lacerated,  contused,  or  open  wounds) ;  but  there  are  slight  differences  in  the 
details  of  the  process,  as  well  as  in  its  duration,  so  that  it  is  customary  to  de- 
scribe the  healing  of  aseptic  closed,  and  open  wounds  separately. 

Repair  of  Aseptic  Closed  Wounds;  "First  Intention." — The  histological  de- 


262 


AMERICAN  PRACTICE  OF  SURGERY. 


V*   Si 


tails  are  seen  best  in  experimental  wounds  on  animals.  The  cellular  changes 
are  best  studied  in  a  non--\'ascular  organ  like  the  cornea ;  the  vascular  changes, 
in  wounds  in  a  relatively  simple  tissue,  such  as  the  ear  or  tongue  of  a  rabbit. 

12  3  The  immediate  result  of  the 

injury  is  hemorrhage.  In  a  few 
hours  more  the  space  between  the 
approximated  edges  is  filled  with 
an  inflammatory  exudate  of  leu- 
cocytes, serum,  fibrin,  and  red 
blood  corpuscles.  The  exudate 
extends  laterally  for  some  dis- 
tance into  the  adjacent  tissues, 
and  on  the  surface  coagulates 
into  a  thin  film  or  crust  (scab). 
The  adjacent  blood-vessels  be- 
come dilated  and  contain  many 
leucocytes.     (Fig.  75.) 

In  a  few  hours  a  new  forma- 
tion ("proliferation")  of  the  epi- 
thelial and  connective-tissue  cells 
adjacent  to  the  wound  begins. 
Mitotic  figures  appear  in  the  epi- 
thelium, and  the  epithelium  be- 
gins to  extend  over  the  surface 
of  the  wound,  beneath  the  crust, 
in  a  thin  layer.  Mitotic  figures 
(see  Fig.  74)  appear  in  the  adja- 
cent connective-tissue  cells,  and  young  connective-tissue  cells,  oval  or  polygonal 
in  shape,  are  formed,  and  extend  into  the  exudate  from  either  side  of  the  wound. 
These  new  connective-tissue  cells  at  first  bear  no  resemblance  to  the  connec- 
tive-tissue cells  from  which  they  are  derived.  The  new  cells  are  produced  in 
excessive  amounts,  so  that  they  are  at  first  more  than  sufficient  to  replace  the 
lost  tissue.  Wliile  this  new  formation  of  cells  is  going  on,  a  new  formation  of 
young  blood-vessels  also  occurs.  These  new  vessels  arise  from  existing  blood- 
vessels, either  small  veins  or  capillaries.  The  endothelial  cells  of  these  capillaries 
enlarge,  send  out  long  processes,  and  undergo  mitosis,  thus  forming  long,  pointed 
processes  of  cells,  which  finally  separate  and  are  arranged  as  blood-vessels, 
that  extend  into  the  exudate.  Some  of  the  processes  unite  with  other  similar 
processes  from  the  same  or  from  the  opposite  side  of  the  wound,  so  as  to  form 
loops  of  new  capillaries.     (Fig.  76.) 

This  process  of  proliferation  of  connective  tissue  and  new  formation  of  blood- 
vessels continues  for  a  variable  time,  depending  upon  the  size  of  the  wound,  the 


[;„„»„. 


Fig.  75. — Repair  of  Wounds;  First  Intention.  Ex- 
perimental incision  in  cornea  of  rabbit.  Condition 
after  the  lapse  of  two  days.  The  picture  illustrates  the 
new  formation  of  connective-tissue  cells  in  a  non-vas- 
cular organ.  1,  Newly  formed  epithelium  growing 
across  the  line  of  incision;  2,  line  of  incision  filled 
with  exudate,  leucocytes,  and  fibrin;  3,  3,  3,  early 
stages   of  proliferating    corneal  corpuscles.      {Original.) 


PROCESSES  OF  REPAIR. 


263 


character  of  the  tissue,  the  amount  of  hemorrhage,  and  the  accuracy  of  approx- 
imation of  the  edges  of  the  wound.  This  combination  of  young  connective  tissue 
and  new  blood-vessels  is  called  "granulation  tissue."  As  the  granulation  tissue 
extends  into   the  exudate,  the  exu-  ^ 

date  is  removed  in  the  manner  al- 
ready described,  and  finally  disap- 
pears. Meanwhile  the  epidermis 
completely  covers  in  the  surface  of 
the  wound,  becomes  thickened,  and 
forms  imperfect  skin  papillae.  The 
time  required  to  cover  in  and  remove 
the  exudate  and  replace  lost  tissue  is 
variable,  depending  upon  the  charac- 
ter and  size  of  the  wound,  but  aver- 
ages from  about  seven  to  ten  days. 
(Fig.  77.) 

The  connective  -  tissue  cells  at 
first  are  oval  or  polygonal,  but  in  a 
few  days  they  become  elongated  and 
spindle-shaped,  and  much  intercellu- 
lar fibrillar  material  appears  between 
them;  and,  finally,  the  nuclei  become 
less  numerous  and  small,  as  in  normal 
connective  tissue,  and  the  intercel- 
lular material  becomes  dense.  Many 
of  the  young  blood-vessels,  at  first 
very  numerous,  disappear,  and  the 
remaining  tissue  shows  very  little 
vascularity.     Thus  is  formed  dense 

"scar  tissue,"  which  is  contractile  and  occupies  much  less  space  than  the 
granulation  tissue.  This  entire  process  of  scar  formation  takes  approximately 
from  ten  days  to  two  weeks.  The  scar  still  continues  to  contract  and  become 
less  vascular,  however,  for  a  long  period — for  weeks  and  often  for  months. 
(Fig.  78.) 

In  human  wounds  the  process  is  the  same  as  in  experimental  wounds,  al- 
though on  account  of  the  extent  of  the  wound  and  the  complex  anatomy  the 
process  appears  more  confused.  The  edges  of  human  wounds  practically  never 
are  exactly  approximated,  and,  as  a  result,  the  interval  to  be  covered  by  the 
proliferating  epithelium  is  greater  than  it  is  in  experimental  wounds,  and  the 
time  required  to  cover  in  the  exudation  is  correspondingly  increased.  The  walls 
of  the  wound  seldom  are  as  distinct  and  sharply  defined  microscopically  as  in 
the  case  of  experimental  wounds,  and  the  exudation  extends  laterally  much  far- 


^J-* 


?ia.»fr 


•-^aiS: 


&# 


Fig.  76. — Repair  of  Wounds;  First  Intention. 
Experimental  incision  in  cornea  of  rabbit.  Con- 
dition after  tlie  lapse  of  four  daj^s.  1,  New  epi- 
thelium which  has  closed  the  incision ;  2,  remnant 
of  exudate  in  the  incision ;  3,  marked  proliferation 
of  corneal  corpuscles.     {Original.) 


264  AMERICAN  PRACTICE  OF  SURGERY. 

ther  beyond  the  line  of  incision  than  in  the  case  of  experimental  wounds.  This 
probably  is  due,  in  part  at  least,  to  the  fact  that  in  surgical  wounds  the  edges 
undergo  a  considerable  amount  of  injury  from  manipulation,  thus  causing 
damage  far  outside  the  mere  line  of  incision.  Consequently,  when  proliferation 
of  cells  and  formation  of  granulation  tissue  begin,  these  processes  are  not  con- 
fined so  closely  to  the  line  of  the  incision  as  in  experimental  wounds,  but  often- 
times extend  several  centimetres  on  either  side  of  the  incision.  Moreover,  in 
human  wounds  different  layers  of  connective  tissue,  fascia,  subcutaneous  fat, 


^0ii^^^^,y^ 


W^ 


Fig.  77. — Repair  of  Wounds ;  First  Intention.  Experimental  incision  in  cornea  of  rabbit.  Con- 
dition after  the  lapse  of  six  days.  1,  New  epithelium  covering  in  incision;  2,  remnant  of  exudate;  3, 
newly  formed  connective  tissue,  derived  from  proliferating  corneal  corpuscles.      {Original,) 

loose  connective  tissue,  etc.,  are  injured,  and  the  rapidity  of  growth  of  the  dif- 
ferent layers  varies  considerably.  The  process,  as  a  rule,  takes  longer  than  in 
experimental  wounds,  and  after  a  few  days  lymphoid  and  plasma  cells  are  seen 
in  the  tissues.  Also,  since  the  deeper  layers  of  the  wounds  seldom  are  exactly 
approximated,  the  amount  of  exudate  between  the  walls  of  the  wound  is  differ- 
ent in  different  places.  Then,  again,  since  the  greater  the  amount  of  exudate 
the  greater  the  length  of  time  required  to  replace  it  by  granulation  tissue,  the 
extent  to  which  organization  is  completed  may  vary  in  different  parts  of  the 
same  wound.  The  time  required  entirely  to  replace  exudate  by  granulation  tis- 
sue ("organization")  amounts,  under  the  most  favorable  circumstances,  to  ten 
days,  and,  even  in  perfectly  aseptic  wounds,  several  days  longer  may  be  re- 
quired.    It  should  be  borne  in  mind  also  that,  even  if  the  exudate  is  entirely  or- 


PROCESSES  OF  REPAIR. 


265 


ganized,  granulation  tissue  in  the  early  stages  contains  relatively  little  intercel- 
lular fibrillar  material,  and  is  therefore  inelastic,  weak,  and  unable  to  stand 
much  strain.     (Fig.  79.) 

After  organization  is  completed  the  intercellular  material  continues  to  form 


'^.^ 


Fig.  78. — Repair  of  Wounds;  First  Intention.  Experimental  incised  wound  through  tongue  of 
rabbit.  Condition  after  the  lapse  of  twenty-four  hours.  1 ,  Epithelium  on  dorsum  of  tongue ;  2,  epithe- 
lium on  bottom  of  tongue;  3,  exudate  of  leucocytes  and  fibrin  at  surface  of  wound;  4,  line  of  incision 
filled  with  exudate,  chiefly  fibrinous;  5,  gap  in  wound,  caused  by  retraction  of  muscle  fibres,  filled  with 
exudate  of  fibrin,  serum,  and  relatively  few  leucocytes;  6,  exudate  of  leucocytes  and  fibrin.  3  and  6 
correspond  to  the  crust  seen  clinically  in  wounds,  but,  on  account  of  the  moisture  of  the  mouth,  it  is 
less  marked  than  usual.      {Original.) 


and  contract,  while  the  blood-vessels  of  the  granulation  tissue  disappear  until  a 
very  dense,  white  scar  tissue  is  left. 

The  gross  appearances  in  human  wounds  correspond  to  the  histological 


266 


M'lERICAN  PRACTICE  OF  SURGERY. 


i 


I 


W:.' 


thr. 


Fig.  79. — Repair  of  Wounds;  First  Intention.  (Experimental.)  Incised  wound  through  tongue 
of  rabbit.  Condition  after  the  lapse  of  eight  days.  Line  of  incision  is  not  cleariy  defined,  owing  to  the 
fact  that  new  connective  tissue  has  formed  beyond  the  limits  of  the  original  incision.  1,  Newly  formed 
epithelium  at  the  point  of  incision,  papillte  irregular;  2,  young  connective  or  granulation  tissue,  with 
fewer  blood-vessels  than  in  preceding  section ;  3,  club-shaped  degenerated  ends  of  muscle  fibres  included 
in  the  young  scar;  4,  new  epithelium  closing  in  line  of  incision.      {Original.) 


PROCESSES  OF  REPAIR. 


267 


Fig.  so. — Repair  of  Wounds;  First  Intention.  Experimental  incised  wound  through  tongue  of 
rabbit.  Condition  after  the  lapse  of  five  days.  1,  Dorsum;  2,  bottom  of  the  tongue;  3,  ingrowth  of 
epithelium  from  edges  of  wound,  closing  surface  of  incision;  4,  remnant  of  exudate  along  line  of  in- 
cision; 5,  newly-formed  granulation  tissue,  arising  from  adjacent  connective  tissue,  and  blood-vessels, 
extending  into  and  replacing  exudate;  6,  point  of  incision  closed  by  newly-formed  epithelium,  which 
forms  nearly  normal  papillte.  Wound  is  wider  on  top  than  below  on  account  of  retraction  of  muscle 
fibres.     (  Original . ) 


268  AMERICAN  PEACTICE  OF  SURGERY. 

changes  just  described.  At  the  end  of  a  few  hours  after  an  incision  has  been 
made  the  edges  of  the  wound  are  sealed  together  by  an  adhesive  layer  of  exu- 
date, slightly  yellow  if  hsemostasis  has  been  complete,  or  tinged  with  red  if 
hemorrhage  has  occurred.  In  from  twenty-four  to  forty-eight  hours  the  sur- 
face of  this  exudate  becomes  hard  and  dry,  and  forms  a  crust  or  scab,  while 
the  edges  are  infiltrated  with  exudate,  and  the  old  blood-vessels  are  somewhat 
dilated.  A  certain  amount  of  redness  of  the  edges  always  appears,  even  when 
the  wound  is  perfectly  aseptic.  The  edges,  too,  are  somewhat  hot  and  tender. 
If  the  edges  of  the  wound  are  torn  apart  at  this  time,  but  little  hemorrhage 
takes  place,  as  no  new  vessels  are  yet  formed,  and  the  walls  of  the  wound 
look  opaque  and  gelatinous  from  the  presence  of  exudate.  If  the  crust  is  re- 
moved in  from  three  to  six  days,  the  surface  of  the  wound  is  seen  to  be  cov- 
ered with  a  thin,  pearly  layer  of  proliferated  epithelium.  If  at  this  time  the 
edges  are  separated  it  will  be  foimd  that  this  can  be  done  only  with  some  diffi- 
culty and  that  the  raw  surfaces  bleed  freely,  on  account  of  injury  to  the  newly 
formed  vessels  of  the  granulation  tissue.  After  about  the  tenth  day  the  crust 
separates  spontaneously  from  the  imderlying  layer  of  newly  formed  epidermis, 
which  is  whiter  and  thicker  than  at  first,  while  the  line  of  incision  is  filled  with 
vascular  red  scar  tissue,  composed  of  spindle-celled  yomig  connective  tissue  in 
which  are  numerous  young  blood-vessels.  In  the  course  of  weeks  or  months  the 
scar  becomes  white  and  narrower  than  it  is  during  the  red-scar  stage,  on  account 
of  the  disappearance  of  the  red  blood-vessels  and  the  conversion  of  the  young 
connective  tissue  into  dense,  contractile  connective  tissue.      (Fig.  80.) 

Repair  of  Aseptic  Open  Wounds  or  Ulcers;  "Second  Intention,"  "Healing 
by  Granulation." — As  the  result  of  injury  there  may  take  place  a  more  or  less 
extensive  destruction  of  the  superficial  and  underlying  tissues  of  the  body, 
producing  a  wound  so  extensive  that  the  edges  of  the  skm  cannot  be  approxi- 
mated so  as  to  close  it.  In  such  cases  the  details  of  the  reparative  process  differ 
from  the  process  which  takes  place  in  closed  wounds,  although  in  their  general 
features  the  two  are  alike. 

In  such  an  injury  of  the  surface  of  the  body  the  hemorrhage  is  usually 
somewhat  copious,  although,  if  the  wound  is  very  superficial,  the  loss  of  blood 
may  be  slight.  The  blood  which  thus  escapes  may  ultimately  coagulate  upon 
the  surface  of  the  wound  to  form  a  red  scab.  In  any  case,  in  a  few  hours  there  is 
formed  upon  the  surface  an  exudate,  which  consists  of  fibrin,  leucocytes,  and 
serum ;  and  this  exudate  also  extends  to  a  considerable  distance  into  the  tissues 
about  the  wound.  Adjacent  blood-vessels  are  moderately  distended.  In  a  few 
hours,  by  the  formation  of  fibrin  and  the  coagulation  of  blood,  the  wound  is 
covered  with  a  crust  or  scab. 

Very  shortly  (twenty-four  hours)  a  proliferation  of  epithelium  at  the  edges 
of  the  wound,  a  new  formation  of  blood-vessels  from  pre-existing  capillaries  and 
veins,  and  a  proliferation  of  connective-tissue  cells  from  the  connective  tissue 


PROCESSES  OF  REPAIR.  269 

about  the  wound  take  place,  just  as  in  the  closed  wounds.  The  epithelium  grows 
into  the  exudate  on  the  surface  as  a  thin,  tongue-like  film,  but  epithelium  has  a 
very  limited  power  of  growth  into  exudate,' and,  if  the  denuded  surface  is  ex- 
tensive, may  be  unable  to  cover  the  surface  of  such  an  open  wound  for  many 


Fig.  81. — Repair  of  Wounds;  Granulation.  Human  wound,  of  several  months'  duration.  1, 
Fibrinous  exudate  on  surface  of  ulcer ;  2,  epithelium  extending  over  surface  of  granulations ;  3,  granula- 
tion tissue,  beneath  exudate;  4,  granulation  tissue  which  has  been  covered  by  ingrowth  of  epithe- 
lium; 5,  5,  base  of  dense  fibrous  tissue,  formerly  granulation  tissue.      (Original.) 

weeks  or  months.    If  the  wound  remains  open  the  epithelium  may  form  a  thick- 
ened, rormded  edge,  dipping  down  into  the  underlying  granulation  tissue. 

By  proliferation  of  the  adjacent  connective  tissue  young  connective-tissue 
cells,  at  first  polygonal  or  oval,  later  spindle-shaped,  and  finally  fibrillated,  are 
formed  and  extend  into  the  exudate  from  the  sides  and  from  below.    Accom- 


270  AMERICAN  PRACTICE  OF  SURGERY. 

panying  these  cells  are  newlj-  formed  vessels,  appearing  as  pointed  processes 
arising  from  the  endothelium  of  existing  blood-vessels.  Ultimately,  these  proc- 
esses divide  and  form  hollow  tubes  or  blood-vessels.  Adjacent  tubes  meet  and 
unite,  thus  forming  vascular  loops.  This  loop  formation  gives  to  that  portion  of 
the  wound  uncovered  with  epithelium  a  granular  appearance;  hence  the  term 
"granulation  tissue."  The  blood-vessels  in  the  granulation  tissue  are  very  abun- 
dant. From  this  surface  of  granulation  tissue  an  inflammatory  exudate  is  given 
off.  Besides  the  leucocytes  many  lymphoid  and  plasma  cells  are  seen  in  the 
granulation  tissue.  Both  lymphoid  and  plasma  cells  are  destroyed  in  part  by 
the  phagocytic  cells  of  the  granulation  tissue.  The  latter  tissue  grows  un- 
til it  reaches  the  level  of  the  surrounding  epidermis,  and,  if  the  wound  is  not  too 
large,  it  ultimately  becomes  covered  by  epidermis.  In  many  cases  the  wound  is 
so  large  that  a  very  long  period  is  reciuired  for  the  accomplishment  of  this. 
In  such  cases  granulation  tissue  grows  above  the  level  of  the  skin,  and  forms 
exuberant  granulations,  or  "proud  flesh."  This  often  is  seen  in  wounds  of  large 
size.  In  small  wounds  the  process  of  repair  may  be  completed  m  a  few  days 
(about  fovu'teen).  The  fibrillation  of  the  connective  tissue  begins  early  in  the 
deeper  layers,  while  the  superficial  layer  continues  to  be  composed  of  polygonal 
or  oval  young  cells.  In  extensive  wounds,  which  are  uncovered  by  epithelium 
after  months,  the  deep  layers  of  the  ulcer  are  composed  of  dense  scar  tissue, 
whose  fibres  run  mostly  parallel  with  the  base  of  the  ulcer. 

The  gross  appearances  correspond  to  the  histological  changes,  and  are  seen, 
e.g.,  in  slightly  " barked"  knuckles.  In  that  case  the  wounded  surface  is  covered 
in  a  few  hours  with  a  clear  yellow  fluid,  which  coagulates  in  a  short  time  and 
forms  a  thin  film  or  crust.  If  the  womid  is  deeper,  hemorrhage  occurs  and  the 
crust  is  red  from  coagulated  blood.  In  two  or  three  days,  if  the  crust  is  removed, 
a  thin,  pearly  film  of  proliferating  epithelium  is  seen  advancing  beneath  the  edge 
of  the  crust.  The  uncovered  portion  of  the  wouncl  shows  a  red,  bleeding,  granu- 
lar surface  of  granulation  tissue.  If  the  wound  heals  promptly  the  epithelium 
covers  the  entire  surface  in  the  form  of  a  thin  film,  the  underlying  granula- 
tion tissue  becomes  fibrillated,  and  forms  a  moderately  elevated,  firm,  red  scar. 
After  weeks  or  months  this  red  scar  disappears.  As  the  vessels  disappear  the 
scar  contracts  and  becomes  markedlj^  smaller  than  at  first,  and  white.    (Fig.  81.) 

If  the  wound  is  extremely  large  or  the  process  of  healing  for  any  reason  de- 
layed, the  wound  may  fail  to  be  covered  by  epithelium  for  weeks  or  months.  In 
that  case  the  edges  of  the  wound  are  covered  with  a  zone  of  epithelium  of  vari- 
able width,  often  very  thick  and  depressed  at  the  edge,  which  advances  very 
slowly.  The  rest  of  the  wound  is  filled  by  reddish,  granular,  moist,  vascular 
granulation  tissue,  which  bleeds  easily  and  often  extends  above  the  level  of  the 
epithelium  at  the  edge.  If  this  layer  be  scraped  off,  the  base  of  the  ulcer  is 
seen  to  consist  of  very  dense,  white  scar  tissue.  This  dense  tissue  makes  the 
best  base  for  the  application  of  skin  grafts,  because  there  is  less  or  no  inflam- 


PROCESSES  OF  REPAIR. 


271 


matory  exudate  in  this  dense  layer,  and  there  is  less  tendency  to  float  off  the 
grafts  by  exudation.     (Fig.  82.) 

Repair  by  "Third  Intention." — Occasionally  in  wounds  in  which  there  has 
been  a  considerable  loss  of  tissue,  it  is  possible,  after  a  few  days,  to  approxi- 
mate the  edges  of  the  wound  in  such  a  way  as  to  convert  what  was  originally  an 
open  wound  into  a  closed  one.  In  such  cases  the  early  stages  of  repair  are  like 
those  of  the  open  wounds,  i.e.,  a  proliferation  of  epithelium  at  the  edges  and  a 
formation  of  granulation  tissue  at  the  bottom  of  the  wound,  take  place.  If  the 
edges  then  are  closed  by  pressure  or  by  approximation  sutures,  surfaces  of 
granulation  tissue,  covered  with  a  varying  amount  of  exudate,  are  approxi- 
mated in  the  deeper  part  of  the  woimd,  i 
while,  at  the  surface,  edges  of  proliferating 
epithelium  are  brought  together.  In  such 
cases,  mider  favorable  circmiistances,  the 
open  woimd  is  converted  into  a  closed 
one,  the  granulation  tissue  from  either 
side  grows  into  and  organizes  the  exu- 
date, the  epithelium  grows  over  and  closes 
in  the  wound,  and  the  later  stages  of  repair 
are  like  those  of  a  wound  which  is  a  closed  ~^^"' 
one  from  the  beginning. 

Infected  wounds.  In  the  woimds  which 
become  infected  by  pyogenic  micro-organ- 
isms there  is  danger  of  general  infection 
or  of  thrombosis  and  embolism,  while  the 
general  character  of  the  local  wound  itself 
may  be  altered,  the  area  of  the  wound  en- 
larged, the  process  of  repair  modified,  and 
the  time  required  for  complete  repair 
prolonged. 

The  pyogenic  organisms  commonly 
present  in  infected  woimds  produce  prac- 
tically one  of  two  types  of  lesion — i.e., 
they  produce  a  marked  solution  of  tissue,  such  as  is  seen  in  the  ordinary  abscess 
due  to  infection  by  Staphylococcus  pyogenes  aureus ;  or  they  produce  a  diffuse 
necrosis  of  tissue,  such  as  is  seen  in  the  phlegmonous  inflammation  produced  by 
the  streptococcus.  The  effect  produced  upon  infected  woimds  varies  with  the 
type  of  infection  present. 

In  closed  wounds  in  which  the  infection  is  of  the  dissolving  type  the  first 
effect  of  infection  is  to  produce  an  increase  in  the  amount  of  inflammatory  exu- 
date present  between  the  edges  of  the  wound,  and  this  increased  exudate  con- 
sists almost  entirely  of  leucocytes,  instead  of  much  fibrin  with  relatively  few 


Fig.  82. — Repair  of  Open  Wounds ;  High 
Power  Details  of  Surface  of  a  Granulating 
W'ound  (see  Fig.  81).  1,  Fibrinous  exudate 
on  surface,  enclosing  partly  disorganized 
leucocytes;  2,  leucocytes;  3,  l>Tnphoid  cells ; 
4,  plasma  cells ;  5,  fibroblasts,  or  newly 
formed  connective-tissue  cells;  6..  new  inter- 
cellular fibrils.      {Original.) 


272  AMERICAN  PRACTICE  OF  SURGERY. 

leucocytes,  as  is  the  case  in  aseptic  wounds.  The  infectious  organisms  also  ex- 
tend rapidly  into  the  tissue  at  the  edges  of  the  wounds,  cause  a  marked  solution 
of  those  tissues,  and  enlarge  the  interval  between  the  edges.  If  the  infection 
occurs  early  the  exudate  maj'  be  discharged  between  the  sutm-es,  but  if  it  occurs 
after  the  edges  are  sealed  together  by  fibrinous  exudate  the  woimd  rapidly  is 
converted  into  an  abscess  cavity,  which  ultimately  may  open  upon  the  surface 
at  some  point  in  the  original  incision;  or  the  entire  margin  of  the  wound,  includ- 
ing the  epidermis,  may  become  dissolved,  and  the  closed  wound  may  be  con- 
verted into  an  open  wound.  In  either  case  the  extent  of  the  wound  is  very  much 
enlarged,  and  the  amount  of  tissue  to  be  replaced  is  much  increased  and  the  time 
required  for  repair  correspondingly  prolonged. 

In  case  the  closed  wound  becomes  infected  by  organisms  which  produce  ne- 
crosis without  marked  solution  of  tissue,  i.e.,  an  acute  inflammation  of  the  phleg- 
monous type,  the  process  of  repair  also  is  affected.  In  such  cases  the  pyogenic 
organisms  extend  into  the  lymphatic  clefts  of  the  tissue  adjacent  to  the  woimd 
and  produce  necrosis  of  tissue,  and  the  necrotic  area  becomes  infiltrated  with  a 
purulent  exudate.  The  necrosis  may  extend  over  an  area  many  times  greater 
than  that  of  the  original  wound.  After  the  infection  has  ceased  or  the  wound 
has  been  artificially  drained,  a  large  slough,  usually  but  not  always  subcutane- 
ous, is  formed  about  the  woimd,  and  this  necrotic  tissue  must  be  replaced  by 
granulation  tissue,  the  time  required  for  this  replacement  corresponding  to  the 
extent  of  the  necrosis.  In  such  cases  the  area  of  granulation  tissue  is  many 
times  greater  than  that  which  would  be  inferred  from  the  line  of  the  original 
incision,  and  maj^,  as  in  the  case  of  a  limb,  lead  to  the  formation  of  a  very 
extensive  subcutaneous  scar,  which  may  surround  the  entire  limb  as  a  buskin  of 
scar  tissue,  which,  by  its  pressure  and  contractility,  may  lead  to  verj'  great  im- 
pairment of  the  functions  of  underh'ing  muscles. 

In  open  wounds  the  result  of  an  infection  is  similar  to  that  in  closed  wounds. 
An  open  wound  infected  with  organisms  which  produce  suppuration  and  solu- 
tion of  tissue  maj^  have  its  original  area  enormously  increased,  while  the  time 
required  for  healing  is  correspondingly  lengthened.  An  open  wound  infected 
with  organisms  which  produce  phlegmonous  inflammation  not  only  has  its 
superficial  area  increased  to  a  considerable  extent,  but  also  becomes  surrounded 
by  a  subcutaneous  slough  which  leads  to  the  same  complications  as  are  seen  in 
infected  open  wounds. 

Principles  of  Treatment  of  Wo^lnds. 

From  a  consideration  of  the  process  of  repair  of  wounds  certain  simple 
fundamental  principles  of  treatment  are  obvious. 

Surgical  cleanliness  is  the  most  important  factor,  and  is  practically  trader 
control.  This  cleanliness  applies  to  the  field  of  operation,  to  the  hands  of  the 
operator,  instriraients,  sponges,  sutures,  dressing,  and  to  all  materials  which  in 


PROCESSES  OF  REPAIR.  273 

any  way  are  brought  into  contact  with  the  wound.  If  perfect  surgical  cleanli- 
ness (asepsis)  is  obtained,  the  amount  of  tissue  to  be  repaired  is  dependent  solely 
upon  the  size  of  the  original  wound.  If  pyogenic  infection  occurs  the  destruction 
of  tissue  depends  upon  the  extent  of  infection,  and  in  all  cases  the  extent  of  the 
wound  and  the  length  of  time  required  to  replace  the  defect  are  increased,  to 
say  nothing  of  the  dangers  of  septicsemia,  etc.' 

Avoidance  of  manipulation  is  also  extremely  desirable.  In  wounds  in  which 
long-continued  or  violent  manipulation  is  carried  on,  the  destruction  of  tissue 
extends  very  widely  beyond  the  mere  limits  of  a  surgeon's  incision,  and  in  such 
cases  the  amount  of  tissue  to  be  replaced  is  much  greater  than  the  mere  incision 
would  require.  Even  in  incised  wounds  the  extent  of  the  reparative  process 
beyond  the  line  of  incision  is  much  greater  than  usually  is  appreciated.  For  this 
reason  it  is  desirable  for  the  surgeon  to  make  free,  sweeping  incisions,  rather  than 
a  series  of  little  cuts. 

Perfect  and  complete  ha?mostasis  also  is  necessary  to  obtain  rapid  healing  of 
wounds.  The  greater  the  amount  of  hemorrhage  between  the  edges  of  aseptic 
wounds  the  greater  the  length  of  time  required  for  healing.  The  hemorrhage 
separates  the  edges  of  the  woimd  and  increases  the  area  to  be  organized  by  gran- 
ulation tissue.  Excessive  amoimt  of  blood  in  a  closed  wound  also  furnishes  an 
excellent  culture  medium  for  the  growth  of  pyogenic  organisms,  if  any  are  present. 

Accurate  closure  and  approximation  of  the  edges  of  wounds  in  which  an  at- 
tempt is  made  to  obtain  primary  union  are  essential.  The  approximation  should 
affect  not  only  the  superficial  edges,  but  especially  the  deeper  layers  of  the 
wound.  Even  in  the  case  of  careful  operators  it  is  astonishing  to  see,  on  examin- 
ing sections  with  a  microscope,  how  very  imperfect  the  closure  of  the  wound  is. 
The  more  accurately  the  epidermis  is  approximated  the  less  the  surface  to  be 
covered  by  proliferating  epithelium.  The  quicker  the  wound  is  covered  by  epi- 
thelium the  less  the  liability  of  infection.  The  more  carefully  the  deeper  layers 
are  approximated  and  dead  spaces  are  obliterated  the  less  the  amount  of  in- 
flammatory exudate  and  blood  to  be  removed  and  organized  by  granulation 
tissue,  and  the  smaller  the  scar. 

Aseptic  protection  of  the  wound  is  essential  during  the  early  days  of  the 
reparative  process.  The  danger  of  secondary  infection  is  over  when  the  wound 
is  covered  by  epithelium  and  the  exudate  is  entirely  replaced  by  granulation 
tissue.  The  power  of  resistance  to  infection  possessed  by  a  wound  covered  with 
granulation  tissue  is  much  greater  than  that  which  it  possesses  in  the  earlier 
stages  before  the  formation  of  granulation  tissue. 

Fixation  of  wounded  tissue  also  is  essential  if  it  be  desired  to  protect  fresh 
or  granulating  edges  of  the  wound  from  further  injury.  This  fixation  may  be 
obtained  in  a  variety  of  ways. 

In  regard  to  open  wounds  there  are  certain  special  precautions.  Surgical 
asepsis  is  as  desirable  in  them  as  in  closed  womids,  but  perfect  asepsis  is  not 


274  AMERICAN  PRACTICE  OF  SURGERY. 

feasible  in  wounds  which  remain  open  for  long  intervals.  The  reason  why  ex- 
tensive open  wounds  do  not  oftener  become  seriously  infected  is  that  healthy 
granulation  tissue  has  a  marked  power  of  resistance  to  absorption  of  pyogenic 
organisms.  On  the  surface  of  open  wounds,  in  the  early  stages,  masses  of 
necrotic  tissue  ("sloughs")  often  are  present.  It  is  better  not  to  attempt  too 
vigorous  removal  of  these,  as  their  forcible  removal  leads  to  repeated  traumat- 
ism of  the  young  granulation  tissue  beneath  them,  with  a  consequent  prolonga- 
tion of  the  time  of  healing  and  increased  danger  of  pyogenic  infection. 

In  open  wounds  also  it  is  desirable  to  keep  the  granulation  tissue  below  the 
level  of  the  advancing  epithelial  edge,  as  epithelium  often  is  unable  to  cover  over 
exuberant  granulations. 

In  many  cases  of  extensive  open  wounds  the  epithelium  ceases  to  advance 
over  the  granulating  area,  and  in  such  cases  it  becomes  necessary  to  cover  in  the 
epithelial  defect  by  small  isolated  grafts,  plastic  flaps,  or  Thiersch  grafts. 

Regulation  of  the  blood  supply  always  is  desirable  in  open  wounds.  Venous 
stasis  always  appears  to  interfere  both  with  the  formation  of  granulation  tissue 
and  with  the  advance  of  the  epithelium.  Prevention  of  venous  stasis  can  be 
obtained  by  pressure,  by  removal  of  varicose  veins,  or  by  position. 

B.  Sutures  and  Other  Foreign  Bodies. 

Various  substances  are  used  for  approximating,  supporting,  and  holding  in 
position  the  edges  of  wounds.  These  mechanical  supports  must  be  retained  in 
the  tissue  until  the  process  of  repair  along  the  line  of  incision  is  so  advanced 
that  the  new  tissue  can  support  the  tension  upon  the  wounded  area.  Usually, 
when  the  wound  is  superficial  the  ends  of  the  suture  are  left  visible,  and  the 
suture  is  removed  when  the  repair  of  the  wound  is  sufficiently  advanced,  al- 
though occasionally  even  skin  sutures  are  buried.  In  deep  wounds  or  in 
wounds  of  the  various  body  cavities,  sutures  or  ligatures  may  be  buried,  and 
cannot  be  removed  after  healing  is  completed. 

The  material  used  as  sutures  may  be  of  animai  origin,  and  therefore  capable 
of  being  ultimately  dissolved  by  the  tissues.  Other  varieties  of  sutures  cannot 
be  dissolved.  Of  the  soluble  sutures  those  most  commonly  used  are  catgut,  both 
plain  and  chromicized,  and  various  animal  tendons.  The  common  insoluble  su- 
tures are  silk,  silkworm  gut,  horsehair,  celloidin,  and  various  metallic  wires. 

The  character  of  the  reaction  produced  in  the  tissues  by  sutures  depends 
partly  upon  whether  the  suture  is  soluble  or  insoluble.  The  primary  effect  of 
the  introduction  of  a  suture  is  the  production  of  a  minute  wound,  which  is  , 
filled  by  a  foreign  body.  The  soluble  sutures,  of  which  catgut  may  be  taken  as  a 
type,  at  first  act  as  a  foreign  body,  but  after  a  time  are  dissolved  by  the  tissues, 
and  the  gap  left  by  their  removal  becomes  filled  with  scar  tissue.  Insoluble 
sutures,  such  as  silk,  persist  indefinitely  unless  removed,  and  finally  are  sur- 
rounded, infiltrated,  and  encapsulated  by  scar  tissue. 


PROCESSES  OF  REPAIR.  275 

Soluble  sutures.  The  introduction  of  the  suture  produces  a  minute  wound. 
Along  the  track  of  the  suture,  extending  into  the  tissues  for  some  distance 
beyond  it,  and  also  extending  into  the  clefts  of  the  suture  itself,  comes  an  in- 
flammatory exudate.  The  suture  itself  becomes  swollen  and  fibrillated,  and 
finally  begins  to  dissolve.  By  the  third  day  a  la3'er  of  granulation  tissue  appears 
about  the  suture.  In  this  granulation  tissue  very  few,  if  any,  giant  cells  are  seen. 
The  granulation  tissue  advances,  while  the  suture  disappears,  and  the  exudation 
is  absorbed,  until  finally  no  remnant  of  suture  can  be  seen  and  the  ti'ack  of  the 
suture  is  occupied  by  granulation  tissue,  which  becomes  fibrillated  and  is  con- 
verted into  a  white  scar. 

The  length  of  time  required  to  effect  the  complete  removal,  of  absorbable  su- 
tures is  variable.  Small-sized,  plain  catgut  requires  approximately  twelve  days; 
larger  sizes  take  somewhat  longer.  Chromicized  catgut  takes  a  variable  time, 
dependent  upon  the  degree  of  chromization,  and  in  some  cases  the  suture  may 
be  rendered  practically  insoluble  and  may  persist  for  months  or  even  years. 
Soluble  sutures  which  become  infected  by  pyogenic  organisms  are  absorbed 
much  less  rapidly  than  sutures  which  remain  aseptic. 

Insoluble  sutures.  As  in  the  case  of  the  soluble  sutures,  the  first  effect  is  the 
production  of  a  minute  wound  containing  a  foreign  body.  Into  this  wound 
comes  an  inflammatory  exudate.  The  exudate  extends  for  some  distance  into 
the  surrounding  tissues  and  also  into  the  meshes  of  the  suture.  In  a  few  hours 
granulation  tissue  is  formed  at  the  periphery  of  the  woimd  and  extends  toward 
the  suture,  and  finally  the  exudate  disappears  and  the  granulation  tissue  sur- 
rounds and  extends  between  the  fibres  of  the  suture.  In  this  granulation  tissue 
are  many  giant  cells.  These  giant  cells  may  persist  for  months  or  years.  In  the 
case  of  superficial  sutures,  which  are  removed  at  the  end  of  ten  or  twelve  days, 
there  is  left  a  minute  wound  lined  with  granulation  tissues,  and  this  wound  in  a 
very  short  time  is  filled  with  new  granulation  tissue. 

Insoluble  sutures,  which  are  fibrillar  like  silk,  are  surrounded  ana  everywhere 
enmeshed  by  the  scar  tissue  which  penetrates  between  the  fibres.  Sutures  like 
wire,  horsehair,  or  silkworm  gut  are  not  fibrillar,  and  no  enmeshing  by  the  scar 
tissue  takes  place. 

C.  Wounds  of  the  Intestine. 

When  any  portion  of  the  intestinal  tract  is  wounded,  it  is  essential  that 
the  wound  be  closed  at  once  in  such  a  way  as  to  render  the  wall  of  the  intes- 
tine watertight  as  soon  as  possible,  so  as  to  prevent  leakage  of  the  infectious 
contents.  Consequently,  many  methods  have  been  devised  for  securing  me- 
chanical closure  as  perfect  as  possible — it  is,  however,  never  absolutely  perfect; 
and  the  serous  surfaces  of  the  cut  edges  always  are  approximated,  because,  if 
mucous-membrane  surfaces  are  brought  together,  repair  does  not  begin  imtil 
the  epitliel-ium  has  been  sloughed  off;  while,  when  the  external  (serous)  sur- 


276  AMERICAN  PRACTICE  OF  SURGERY. 

faces  are  approximated,  the  production  of  fibrinous  exudate  is  very  rapid,  and 
in  a  very  few  liours  the  wound  is  rendered  watertight,  provided  it  be  not  sub- 
jected to  too  much  mechanical  tension.  Many  methods  of  suture  have  been  de- 
vised for  closing  the  mtestine.  In  some  cases  the  suture  may  penetrate  all  the 
coats  of  the  gut,  but  these  sutures  are,  as  a  rule,  applied  merely  to  give  fixation 
of  the  wounded  edges.  The  sutures  which  approximate  the  serous  surfaces  of 
the  intestine  should  not  extend  from  the  lumen  of  the  intestine  to  the  peritoneal 
cavity,  for  if  they  do  they  make  a  wound  that  is  connected  with  the  infected  intes- 
tinal canal,  and  infection  along  the  suture  may  lead  to  infection  of  the  general 
peritoneal  cavity.  The  best  suture  is  one  which  gives  the  strongest  and_  most 
perfect  immediate  mechanical  closure  of  the  wound  without  allowing  any  con- 
nection of  infected  intestine  with  the  peritoneal  cavity,  and  also  gives  the  most 
perfect  approximation  of  the  edges  of  the  external  serous  coat  without  diminu- 
tion of  the  calibre  of  the  intestine.  It  may  be  said  that  without  doubt  the  best 
suture  material  is,  on  the  whole,  silk  or  celloidin,  as  animal  sutures  soften  so 
early  that  they  do  not  maintain  perfect  approximation  mitil  the  wound  is  com- 
pletely organized.  Mechanical  devices  should  be  used  only  for  special  clinical 
reasons.  The  process  of  repair  is  the  same,  no  matter  what  mechanical  method 
is  used,  but  the  process  which  I  have  described  above  is  such  as  is  seen  after 
suture. 

In  intestinal  wounds  the  mucous  membrane  is  inverted  and  the  serous  sur- 
faces are  approximated.  The  interval  between  the  approximated  serous  sur- 
faces thereupon  quickly  fills  with  inflammatory  exudate,  and  all  layers  of  the 
cut  intestine  are  infiltrated.  In  a  few  hours  the  endothelium  of  the  serous  mem- 
brane becomes  necrotic  between  the  sutured  edges,  as  well  as  for  a  considerable 
distance  beyond  the  line  of  incision,  and  the  latter  can  no  longer  be  recog- 
nized. Exudate  covers  the  external  surface  of  the  gut  for  a  considerable  dis- 
tance beyond  the  wormd,  and  thus  in  a  few  hours  the  wound  becomes  imper- 
meable to  fluids,  if  too  much  tension  be  not  applied.  The  inverted  mucous 
membrane  becomes  necrotic,  and  always  is  more  or  less  infected.  Through  a 
process  of  necrosis  the  invaginated  portion  of  the  gut  becomes  dissolved.  In 
a  very  few  hours  (twenty-four)  a  marked  proliferation  of  the  connective  tissue, 
chiefly  of  the  subserous  connective  tissue,  takes  place,  together  with  a  new 
formation  of  blood-vessels.  This  granulation  tissue  very  rapidly  extends 
into  the  exudate  between  the  inverted  serous  surfaces,  and  in  a  relatively 
short  time,  often  by  the  seventh  day,  the  exudate  is  entirely  removed  and  re- 
placed by  granulation  tissue.  Wliile  this  is  taking  place,  the  inverted  edges 
have  sloughed,  forming  an  ulcer  on  the  inner  surface  of  the  gut,  beneath  which 
granulation  tissue  also  forms.  The  intestinal  epithelium  at  the  edges  of  this 
ulcer  proliferates  and  extends  over  the  surface  of  the  ulcer,  just  as  does  epithe- 
lium in  ulcers  of  the  surface  of  the  body.  Wliile  these  changes  are  taking  place 
inside  the  gut,  the  exudate  on  the  outside  also  has  been  replaced  by  granulation 


PROCESSES  OF  REPAIR.  277 

tissue.  Finallj^,  the  granulation  tissue  between  the  inverted  serous  surfaces  be- 
comes dense  scar  tissue,  and  the  internal  ulcer  is  covered  by  intestinal  epithe- 
lium, which  even  may  form  imperfect  glands.  In  time,  the  restoration  is  so 
complete  that  it  may  be  impossible  to  find  the  site  of  the  wound  by  gross 
examination. 

The  healing  usually  proceeds  more  rapidly  than  it  does  in  wounds  of  the  sur- 
face of  the  body.  The  wound  is  sealed  by  fibrinous  exudate  within  a  very  few 
hours,  although,  of  course,  the  fibrin  can  easily  be  displaced  under  great  tension. 
In  many  cases  the  organization  of  the  exudate  is  completed  in  seven  days,  al- 
though it  is  to  be  remembered  that  granulation  tissue  at  this  time  still  is  very 
fragile.  Rapidity  of  union  is  favored  by  accurate  approximation  of  serous  sur- 
faces and  by  avoiding,  as  far  as  possible,  any  manipulation  that  might  disturb 
the  approxuTiated  edges. 

D.  Repair  of   Tendons. 

Tendons,  aponeuroses,  and  ligaments  are  special  types  of  connective  tissue. 
What  has  already  been  said  about  the  repair  of  connective  tissues  in  wounds  ap- 
plies in  a  general  way  to  the  repair  of  tendons,  but  tendons  are  connective  tissue 
with  a  special  function  and  a  special  structure,  and  the  details  of  the  process  of 
repair,  in  these  structures,  vary  somewhat  from  the  process  as  seen  in,  e.g.,  sub- 
cutaneous connective  tissue.  It  will,  therefore,  be  proper  to  make  special  men- 
tion of  some  of  these  details. 

To  understand  the  process  of  repair  it  is  necessary  to  bear  in  mind  the  anat- 
omy of  a  normal  tendon.  Tendons  are  composed  of  the  densest  sort  of  fibrous 
tissue  arrayed  in  parallel  bundles,  closely  connected,  with  relatively  few  elastic- 
tissue  fibres.  Surrounding  the  tendons  is  a  layer  of  loose  areolar  tissue  (the 
peritendineum),  from  which  septa  run  into  the  tendon,  dividing  it  into  larger 
(secondary)  and  smaller  (primary)  bundles  of  dense  fibres.  These  dense  fibres 
appear,  under  the  microscope,  wavy  from  contraction,  and  anastomose  more  or 
less  with  one  another.  Between  the  fibres  are  cells  which  on  long  section  are 
oval  or  rectangular,  but  on  cross  section  are  stellate,  and  are  united  to  other 
similar  cells  by  processes,  thus  separating  the  fibres  into  bundles. 

When  a  tendon  is  divided  there  always  is  considerable  retraction  of  the  di- 
vided ends.  This  is  due  partly  to  contraction  of  the  muscle  of  the  tendon,  and 
partly  to  contraction  of  the  fibres  of  the  tendon  itself.  The  peritendineum  sel- 
dom retracts  to  the  same  extent  as  the  tendon,  but  becomes  markedly  fibrillar 
and  folds  over  the  retracted  end  of  the  tendon.  Into  the  interval  between  the 
retracted  tendon  ends  comes  an  inflammatory  exudate,  with  perhaps  some 
hemorrhage.  The  mesh  of  the  peritendineum  is  filled  with  exudate,  but  this 
exudate  extends  only  a  little  way  into  the  cut  ends  of  the  tendon  itself.  Very 
early  there  begins  a  rapid  proliferation  of  connective-tissue  cells  from  the 
connective  tissue  of  the  mesh  of  the  peritendineum,  not  only  between  the  re- 


278  AMERICAN  PRACTICE  OF  SURGERY. 

tracted  ends  of  the  tendon,  but  also  from  the  peritendineum  outside  the  tendon 
ends,  thus  forming  a  spindle-shaped  swelling  much  like  the  callus  of  a  fracture. 
At  the  same  time  new  blood-vessels  are  formed.  In  this  spindle  of  granulation 
tissue  intercellular  fibrils  appear  very  early  to  an  extent  much  more  marked  than 
in  ordinary  connective  tissue.  The  cells  of  the  tendon  take  very  little  part  in 
this  process  of  proliferation,  and  the  original  dense  fibres  of  the  tendon  not  at 
all.  There  is,  however,  marked  proliferation  of  the  connective-tissue  cells  of  the 
connective-tissue  septa  of  the  tendon,  which  extend  between  the  dense  fibres  of 
the  tendon  proper.  As  the  proliferation  continues  the  exudate  disappears,  and 
finally  the  cut  ends  are  joined  by  a  spindle  of  granulation  tissue.  The  blood- 
vessels disappear  very  early,  granulation-tissue  fibrils  are  formed  in  large 
amounts,  and  a  spindle  of  dense,  fibrous  tissue  joins  the  cut  ends.  In  time,  the 
new  intercellular  fibrils  cannot  be  distinguished  from  the  original  tendon  fibres, 
the  new  tissue  becomes  of  the  same  size  as  the  original  tendon,  and  cannot  be 
distinguished  by  the  naked  eye  from  the  uninjured  tendon. 

The  time  required  for  the  process  is  variable,  depending  upon  the  size  of  the 
tendon  and  upon  the  amount  of  separation.  The  formation  of  completely  or- 
ganized, dense,  fibrous  tissue  in  smaller  tendons  is  completed  in  about  two  weeks. 
In  larger  tendons  the  process  covers  a  somewhat  longer  period  of  time.  In 
practically  every  case  the  tendon  is  sufficientlj^  regenerated  to  allow  passive 
motion  in  about  three  weeks. 

In  some  cases  tendons  fail  to  unite  or  may  unite  imperfectly.  If  the  cut  ten- 
don ends  are  too  widely  separated,  the  connective  tissue  reproduced  by  adjacent 
connective  tissue  may  interpose,  and  the  gap  be  filled  with  ordinary  scar  tissue 
instead  of  with  connective  tissue  arising  from  the  peritendineum;  or  again,  even 
if  the  two  tendinous  ends  become  united  with  new  tendon  derived  from  the 
peritendineum,  the  new  tissue  may  become  adherent  to  the  new  connective  tissue 
of  the  adjacent  skin,  etc.,  and  thus  imperfect  function  may  result.  Also,  where 
several  tendons  are  divided  in  one  wound,  e.g.,  in  accidental  wounds  about  the 
wrist,  especially  if  the  tendons  are  divided  in  some  place  where  the  tendon 
sheaths  are  not  sharply  defined,  the  newly  formed  tissue  between  the  ends  of 
adjacent  tendons  may  unite  into  one  common  mass,  thus  leading  to  very  im- 
perfect function.  In  the  same  way,  even  when  only  one  tendon  is  divided,  it 
may  adhere  to  the  connective-tissue  wall  of  its  sheath.  In  the  case  of  tendons 
lying  m  sharply  defined  sheaths,  a  large  amount  of  separation  is  possible.  In 
cases  where  several  tendons  lie  close  together,  less  separation  is  possible.  In 
such  cases  it  often  is  better  to  fill  the  gap  by  some  one  of  the  many  methods 
of  splicing  the  tendon,  in  order  to  be  sure  that  the  line  of  the  tendon  is  main- 
tained by  peritendineum  from  which  the  new  tendon  is  to  be  formed. 


PROCESSES  OF  REPAIR.  279 

E.  Repair  of  Fractures. 

The  bones,  like  the  tendons,  are  essentially  a  modified  connective  tissue  with 
special  functions,  the  first  of  which  is  to  furnish  support ;  the  second  is  connected 
with  the  function  of  production  of  the  blood  corpuscles.  The  supporting  part 
of  the  bones  is  a  modified  connective  tissue,  in  which  lime  salts  are  deposited. 
To  understand  the  process  of  repair  of  injuries  to  bone,  it  is  necessary  to  bear 
in  mind  the  minute  anatomy  of  the  bones. 

The  bones  consist  of  a  supporting  framework,  rigid  from  the  presence  of  lime 
salts,  and  of  a  soft  central  portion,  the  marrow.  On  the  external  surface  of  the 
bone  is  a  thin  layer  of  peculiar  structure,  corresponding  to  the  "bast"  of  a  tree — 
the  "periosteum."  This  external  la}^er  is  one  of  the  two  actively  growing  por- 
tions of  the  bone.  Lining  the  inner  surface  of  the  supporting,  portion  of  the  bone 
are  cells  which  have  the  same  function  of  bone  production  as  the  deeper  cells  of 
the  periosteum,  the  "endosteum."  The  calcified  portion  of  the  bone  forms  an 
external  dense  shell,  or  "cortex,"  surrounding  the  more  or  less  open  central 
"marrow  cavity."  From  the  inner  surface  of  the  cortex  irregular  beams  or 
"trabeculte"  of  bone  extend  inward,  especially  near  the  articular  ends  of  the 
marrow,  forming  an  irregular  meshwork  of  rigid  beams,  which  adds  to  the 
strength  of  the  bone  and  serves  as  a  support.  The  trabecule  make  an  irregular 
meshwork  of  bone,  but  the  spaces  of  the  mesh  are  not  closed  spaces,  but  irregu- 
lar spaces  connecting  one  with  another,  although  the  course  of  the  communica- 
tion may  be  very  devious.  The  relative  amount  of  supporting  trabeculse  varies 
in  different  bones  and  in  different  portions  of  the  same  bone.  In  the  flat  bones 
of  the  skull,  and  in  the  short  bones,  the  meshwork  of  the  trabeculse  is  relatively 
large  and  is  fairly  uniformly  distributed.  In  the  long  bones,  in  the  articulating 
end,  the  trabeculse  are  numerous,  and  form  a  rather  dense  internal  meshwork  of 
bone,  which  adds  to  the  strength  of  the  structure.  The  trabeculse  in  this  portion 
of  the  bone  are  not  arranged  irregularly,  but  are  distributed  in  such  a  way  as  to 
give  the  maximum  of  strength,  l^eing  arranged  roughl}^  along  the  lines  of  "  stress 
and  strain,"  much  as  an  engineer  would  arrange  the  structure  of  a  bridge  or  der- 
rick. The  character  of  the  marrow  varies  at  different  ages,  and  in  different 
bones  at  the  same  age.  In  infants  and  young  people  the  marrow  is  red  and  con- 
tains many  hemopoietic  cells.  In  adults  the  marrow  of  the  long  bones  is  yellow, 
and  consists  chiefly  of  fat  cells.  The  marrow  of  the  short  bones  more  closely 
resembles  the  red  marrow  of  children.  In  old  people  the  marrow  often  is  of  a 
myxomatous  structure.  The  marrow  consists  of  a  framework  of  connective  tis- 
sue, supporting  blood-making  or  fat  cells.  The  periosteum  is  a  membrane  sur- 
rounding the  cortex,  composed  of  a  deep  layer  of  polygonal  cells,  which  have  the 
power  of  depositing  bone,  while  the  outer  layer  is  fibrous,  much  like  dense  fibrous 
tissue.  The  periosteum  is  the  seat  of  the  peripheral  growth  of  bone.  The  inner 
surface  of  the  cortex  and  the  trabecule  are  lined  with  a  membrane  of  cells  (the 


280  AilERICAN  PRACTICE  OF  SURGERY. 

endosteum),  which  have  the  same  function  for  the  internal  surface  of  the  sup- 
porting frameworlv  that  the  periosteum  has  for  the  periphery.  Under  normal 
conditions  the  endosteum  may  be  undemonstrable  in  ordinary  sections,  but  in 
bone  that  is  undergoing  repair  this  internal  osteogenetic  layer  is  clearly  visible. 
The  cortical  bone  has  a  laminated  structure,  and  at  intervals  between  the  1am- 
inai  are  open  spaces,  or  "lacuna,"  in  which  lie  living  bone  cells,  or  "bone  cor- 
puscles." The  lacuna?  communicate  one  with  another  by  delicate  canals,  or 
"canahculse,"  in  which  run  processes  of  the  bone  corpuscles.  In  places  in  the 
cortical  bone  are  open  canals  of  larger  size,  surrounded  by  concentric  bone  lam- 
ins,  "Haversian  canals,"  in  which  blood-vessels  and  nerves  run.  The  spaces  be- 
tween the  trabeculfe  are  the  "alveolar  spaces." 

The  bones  develop  in  different  ways.  Most  of  the  bones  are  preformed  in 
cartilage,  arising  from  mesoblastic  cells,  and  finally  become  converted  into  true 
bone.  This  process  of  ossification  in  the  long  bones  begins  at  the  middle  of  the 
shaft,  and  extends  in  both  directions  toward  the  ends  of  the  bone.  Consequently 
the  ends  of  the  bone  persist  as  cartilage  long  after  the  shaft  is  ossified.  These 
cartilaginous  ends  form  the  "epiphyses."  The  intermediate  line  between  the 
epiphysis  and  the  ossified  shaft,  or  diaphysis,  is  the  so-called  epiphyseal  line,  and 
is  the  point  at  which  new  bone  is  formed  to  increase  the  length  of  the  bone. 

Some  of  the  bones,  notably  the  bones  of  the  vault  of  the  cranium,  are  not 
preformed  in  cartilage,  but  are  formed  directly  from  mesoblastic  cells,  without 
the  intervention  of  cartilage.    These  are  the  so-called  "membranous  bones." 

The  process  of  repair  by  the  osteogenetic  tissues,  although  essentially  the 
same  as  that  which  takes  place  after  a  fracture  of  bone  or  after  its  partial  or 
complete  removal,  differs  from  it,  nevertheless,  in  certain  details ;  hence  the  two 
processes  will  be  described  separately. 

Fractures.  If  a  bone  is  fractured,  usually  the  broken  ends  are  more  or  less 
displaced,  fragments  of  bone  may  lie  loose  in  the  tissues,  and  there  usually  is  more 
or  less  stripping  of  the  periosteum,  and  crushing  of  the  adjacent  soft  parts,  with 
some  hemorrhage ;  i.e.,  there  is  not  only  an  injury  of  the  bone,  but  also  a  more 
or  less  extensive  injury  of  the  soft  parts.  After  a  few  daj's  a  fusiform  mass  (cal- 
lus) is  formed  about  the  broken  ends,  and  persists  for  a  variable  length  of  time, 
constantly  becoming  more  rigid  and  dense.  After  the  ends  of  the  bone  are  firmly 
imited,  the  callus  disappears  more  or  less  completely,  and,  if  the  broken  ends 
have  been  accurately  approximated,  the  external  appearance  of  the  bone  be- 
comes normal. 

The  details  of  the  reparative  process  are  best  studied  in  bones  in  which  a  loss 
of  tissue  has  been  produced  without  dislocation  or  displacement  of  fragments, 
e.g.,  by  drilling  a  small  hole  vertically  into  the  shaft  of  a  bone  of  an  animal.  In 
this  way  the  process  can  be  studied  in  its  simplest  form  and  the  more  compli- 
cated process  of  repair  in  complete  fractures  will  then  be  more  easily  understood. 

In  experimental  drill  holes  the  first  result  of  the  injury  is  hemorrhage  into 


PROCESSES  OF  REPAIR.  281 

the  hole,  followed  in  a  few  hours  by  an  inflammatory  exudate  of  leucocytes, 
serum,  and  fibrin.  By  the  second  day  a  proliferation  of  periosteal  cells  and  of  the 
endothelium  of  adjacent  blood-vessels  begins,  both  on  the  outside  of,  and  within, 
the  cortex  of  the  bone.  The  proliferation  of  cells  external  to  the  cortex  arises 
from  the  cells  of  the  periosteum  at  the  periphery  of  the  drill  holes,  and  results  in 
the  formation  of  a  mass  of  tissue,  thickest  over  the  hole  and  thinnest  at  the  edges. 
Among  these  proliferated  periosteal  cells  are  numerous  young  blood-vessels. 
This  mass  of  new  cells  and  vessels  forms  the  earliest  stage  of  the  "  external  cal- 
lus." The  internal  proliferation  arises  from  the  layer  of  cells  of  the  marrow  which 
lies  next  to  the  cortex  and  trabeculae  (endosteum);  it  forms  a  mass  of  cells 
about  the  drill  hole,  and  is  thickest  opposite  the  hole.  This  is  the  so-called  "  in- 
ternal" or  "myelogenous  callus."  In  this  callus  also  may  be  numerous  new 
blood-vessels.  Besides  the  proliferation  of  osteogenetic  cells  (periosteal  cells 
externally  and  the  endosteal  internally),  there  is  a  proliferation  of  ordinary 
connective  tissue.  The  cells  derived  from  this  ordinary  connective  tissue  can- 
not at  first  be  distinguished  by  their  appearance  from  the  cells  of  osteogenetic 
origin.     (See  Plate  A.) 

By  the  fourth  day,  in  both  the  external  and  the  internal  callus,  there  ap- 
pears, between  the  osteogenetic  cells,  a  homogeneous  intercellular  substance. 
This  homogeneous  substance  ("ostoid")  marks  the  beginning  of  new-formed 
trabeculse,  for  in  a  short  time  lime  salts  are  deposited  in  this  material.  As  the 
process  continues,  some  of  the  proliferated  cells  are  retained  in  the  mass  of  cal- 
cified material  and  become  bone  corpuscles.  Other  cells,  at  the  periphery  of  the 
calcified,  homogeneous  material,  deposit  successive  layers  of  osteoid  tissue  upon 
the  external  surface  of  the  young  trabeculae,  producing  a  steady  increase  in  size. 
These  bone-depositing  cells  are  the  osteoblasts.  The  spaces  between  the  newly 
formed  trabecule  (marrow  spaces)  are  filled  with  spindle-shaped  yoimg  connec- 
tive-tissue cells,  probably  not  of  osteogenetic  origin.  At  this  stage  the  old  cor- 
tical bone  takes  practically  no  part  in  the  process  of  proliferation,  but  the  drill 
hole  is  filled  with  granulation  tissue  derived  from  the  periosteum  and  endosteum. 

By  the  end  of  a  week  the  exudate  usually  has  almost  entirely  disappeared. 
Numerous  well-developed  young  trabecule  are  formed  in  the  external  and  in- 
ternal callus.  The  drill  hole  is  filled  with  granulation  tissue  of  osteogenetic 
origin,  one  part  of  it  arising  from  the  external  callus  and  growing  inward,  while 
the  other  arises  from  the  internal  callus  and  grows  outward.  In  this  granulation 
tissue  osteoid  tissue  appears  between  the  cells  and  forms  the  basis  of  new  trabec- 
ulte,  which  are  to  replace  the  defect  in  the  cortex  caused  by  the  drill.  The  corti- 
cal bone  itself  remains  practically  inert  and  does  not  assist  in  the  formation  of  new 
bone.  The  trabecule  at  this  period  are  arranged,  in  a  general  way,  at  right  angles 
to  the  course  of  the  laminae  of  the  cortical  bone.  The  surface  of  the  trabeculae  is 
studded  with  osteoblasts.  Other  cells,  larger  than  the  osteoblasts,  with  many  nu- 
clei, are  fairly  numerous  at  this  time.    These  giant  cells  or  osteoclasts  usually  lie 


282  AMERICAN  PRACTICE  OF  SURGERY. 

in  little  bays  or  depressions  on  the  surface  of  the  new  trabeculae,  and  have  the 
power  of  dissolving  or  destroying  the  bony  tissue  of  the  new  trabeculte.  As  a  re- 
sult of  the  activity  of  these  two  varieties  of  cells— osteoblasts  and  osteoclasts — two 
processes  are  going  on  at  the  same  time  in  the  bony  portion  of  the  callus :  bone 
formation  by  osteoblasts,  and  bone  destruction  by  osteoclasts.  Consequently,  the 
form  of  any  given  trabeculae.  is  constantly  changing.  The  tendency  of  the  two 
processes  is  so  to  arrange  the  new  bone  that  it  shall  take  up  weight  to  tlie  best  ad- 
vantage with  the  smallest  amomit  of  bone.  Finally,  in  the  course  of  three  or  four 
weeks,  the  new  trabecular  which  are  formed  in  the  granulation  tissue  between  the 
broken  cortical  ends  become  attached  to  the  cortex,  and  completely  fill  the  de- 
fect caused  by  the  drill  hole.  The  external  callus,  therefore,  no  longer  is  neces- 
sary to  maintain  the  strength  of  the  bone,  and  by  the  action  of  the  osteoclasts 
is  absorbed  and  nearly  or  entirely  disappears.  The  same  is  true  of  the  internal 
callus.  The  trabeculte  in  the  drill  hole,  by  the  combined  action  of  osteoblasts 
and  osteoclasts,  come  to  be  arranged  in  the  same  general  direction  as  the  trabec- 
ulge  of  the  original  cortex,  and  repair  is  practically  completed.  The  bone  which 
fills  the  drill  hole  continues  to  become  denser  for  many  months  after  the  injury, 
and  finally  it  replaces  the  old  bone  so  perfectly  that  it  is  difficult  to  determine 
the  point  of  injury.     (See  Fig.  S3.) 

In  the  simplest  process  of  repair  of  an  experimental  drill  hole,  the  transition 
from  granulation  tissue  of  osteogenetic  origin  to  bone  is  direct,  without  the  in- 
tervention of  cartilage.  This  process  corresponds  roughly  to  the  formation  of 
bone  as  it  is  seen  in  the  so-called  membranous  bones.  In  many  cases  of  simple 
injury  of  bone  by  the  drill,  however,  the  process  produces  granulation  tissue  of 
osteogenetic  origin,  as  already  described:  but  this  granulation  tissue  becomes 
at  first  converted  into  cartilage.  In  this  case  some  of  the  cells  become  sur- 
rounded by  a  homogeneous,  intercellular  material,  in  which  lime  salts  are  not 
deposited.  Some  of  the  cells  included  in  this  matrix  take  on  the  appearance  of 
cartilage  cells,  and  in  this  way  both  external  and  internal  callus  may  at  first  be 
formed  of  hyaline  cartilage  to  a  greater  or  less  extent.  Later,  as  the  process 
advances,  this  cartilage  becomes  converted  into  bone.  In  fractiu-es  in  animals,  in 
which  the  fracture  is  complete,  and  probably  in  all  human  fractures,  this  forma- 
tion of  bony  callus  via  cartilage  is  always  the  course  of  a  greater  or  less  part  of 
the  callus. 

In  complete  fractures  of  bone  the  general  process  of  repair  is  the  same  as  that 
observed  in  experimental  drill  holes,  Ijut  the  details  vary  somewhat.  In  complete 
fractures  the  ends  of  the  bones  are  nearly  always  somewhat  dislocated,  so  that 
perfect  approximation  of  the  ends  seldom  occurs,  and  as  a  rule  the  injury  to  the 
soft  parts  is  excessive.  ^Yhen  cell  proliferation  begins  it  arises  internally  from  the 
endosteum  ("medullary  callus"),  and  externally  both  from  the  periosteum  and 
from  the  connective  tissue  of  the  adjacent  soft  parts  ("external  callus").  The 
external  callus  appears  relatively  nmch  largei'  than  in  drill-hole  fractures,  and 


EXPLANATION  OF  PLATE  A. 

Repair  of  Fractures.  (Experimeiital.)  Transverse  section  through  a  vertical  drill-hole  in  the 
femur  of  a  rabbit.  Condition  after  the  lapse  of  eight  days.  1,  Drill-hole  filled  with  loose  fragments 
of  bone  and  granulation  tissue;  2,  remnant  of  fibrin  from  inflammatory  exudate;  3,  margin  of  drill- 
hole in  cortical  bone — no  proliferation  of  this  dense  bone:  4,  internal  callus,  arising  from  endosteum; 
5,  5,  external  callus,  arising  from  periosteum,  and  being  partly  preformed  cartilage  and  partly  a  direct 
bony  formation;  6,  scar  tissue  in  marrow  canal,  coming  chiefly  from  reticulum  of  marrow;  7,  7,  cor- 
tex of-femur.     (Original.) 


AMERICAN  PRACTICE  OF  SURGERY 


PLATE  A 


ri,"V'^ 


PROCESSES  OF  REPAIR. 


PROCESSES  OF  REPAIR. 


283 


forms  a  large,  fusiform  mass,  including  the  fractured  ends.  At  first  no  distinc- 
tion can  be  made  between  the  cells  which  arise  from  the  periosteum  and  those 
which  arise  from  the  soft  tissues.  WHren  ti'abeculce  form  in  the  callus  they  may 
form  directly  from  the  osteogenetic  granulation  tissue,  as  in  the  simplest  form 
of  drill-hole  fracture ;  or,  more  often,  the  first  step  is  a  conversion  of  the  granu- 
lation tissue  into  hyaline  cartilage.  As  the  process  advances,  the  deeper  layers 
of  this  cartilage — those  nearest  the  cortical  bone — are  converted  (metaplasia) 
into  bone,  and  the  process  continues  until  the  greater  portion  of  the  callus  be- 


"P^^i^^ 


c*.'^yT>«a^.«^ 


Fig.  S3. — Repair  of  Fractures.  (Experimental.)  Transverse  section  tlirougli  a  \'ertical  drill- 
"hole  in  tlie  femur  of  a  rabbit.  Condition  after  tlie  lapse  of  twenty  days.  1,  Drill-hole  filled  with 
newly  formed  trabeculce,  derived  from  external  and  internal  callus ;  2,  external  callus  wliich  has  under- 
gone partial  absorption;  3,  internal  callus  partly  absorbed;  4,  new  bone  which  replaces  lost  bone, 
adherent  to  original  cortical  bone :  5,  similar  condition,  artificially  separated  from  original  cortex, 
showing  that  union  is  insecure  for  some  time.  Notice  that  new  trabecul^e  are  beginning  to  assume  a 
position  like  that  of  the  original  bone.      (Original.) 

■comes  bone.  The  same  process  may  be  seen,  although  usually  not  so  well 
marked,  in  the  internal  callus.  As  in  experimental  fractures,  the  cortical  bone 
of  the  fractured  ends  remains  practicalh^  inert,  and  takes  no  part  in  the  pro- 
duction of  the  new  trabeculae,  which  arise  almost  entirely  from  the  periosteum 
and  endosteum.  The  trabecule  from  these  two  bone-forming  layers  extend 
between  the  broken  ends,  and  finally  become  attached  to  the  cortical  bone, 
and  more  or  less  completely  restore  the  line  of  the  cortex.  At  first,  this  new 
bone  is  composed  of  young  trabeculse,  studded  with  osteoblasts  and  osteoclasts, 
with  narrow  spaces  between  the  trabeculfe  filled  with  spmdle-celled  connective 


284  AMERICAN  PRACTICE  OF  SURGERY. 

tissue.  The  trabecular  often  are  arranged  at  right  angles  to  the  line  of  the 
laminae,  of  the  cortical  bone.  Ultimately,  the  narrow  spaces  disappear  as  the 
trabecule  increase  in  size,  and  by  growth  of  the  trabeculse  new  dense  cortical 
bone  is  formed  to  replace  the  defect  caused  by  fracture.  By  the  combined  ac- 
tion of  osteoblasts  and  osteoclasts,  the  laminae  of  this  new  dense  cortex  resume 
the  same  general  direction  as  the  laminae  of  the  injured  cortex,  provided  the 
fractured  ends  have  been  accurately  approximated. 

The  ultimate  fate  of  the  bone  of  the  external  callus  depends  upon  the  accu- 
racy of  approximation  of  the  fractured  ends  of  the  bone.  If  they  are  so  ap- 
proximated as  practically  to  restore  the  original  contour  of  the  bone,  after  a 
time  there  is  marked  or  complete  absorption  of  the  external  callus,  and  the  bone 
resumes  its  original  contour.  If,  however,  the  dislocation  of  the  fractured  ends 
is  extreme  and  is  not  reduced,  much  of  the  external  callus  persists  after  bony 
union  has  taken  place,  and  the  laminae  of  the  callus  which  persists  are  not  paral- 
lel to  the  laminae  of  the  unbroken  cortex,  but  are  arranged  in  such  a  way  as  to 
take  up  weight  to  the  best  mechanical  advantage.  A  persistence  of  a  marked 
amount  of  external  callus  always  indicates  malposition  of  the  fractured  ends. 
This  fact  is  of  great  clinical  importance.  The  time  required  to  repair  any  given 
fracture  depends  upon  the  size  of  the  fractured  bone,  upon  the  accuracy  with 
which  the  ends  are  approximated,  and  upon  the  care  and  perfection  with  which 
they  are  immobilized. 

In  some  cases  bony  union  is  delayed  for  long  periods,  or,  indeed,  may  never 
take  place.  In  many  cases  the  reason  for  failure  to  unite  is  not  clear.  Some- 
times it  appears  to  be  due  to  the  inclusion  of  soft  tissues  between  the  broken 
ends,  thus  preventing  the  union  of  the  two  sides  of  the  external  callus.  This 
cause,  however,  certainly  is  a  rare  one.  In  other  cases  tissue  having  the  struct- 
ure of  bone  (osteoid  tissue)  forms  an  external  callus,  but  no  deposit  of  lime  salts 
takes  place.  The  cause  of  this  is  unknown.  In  some  cases  the  fractured  ends 
are  united  by  dense  scar  tissue  only,  without  any  bone  formation.  This  pro- 
duces a  flail-like  joint,  or  "syndesmosis."  Or  one  fractiu-ed  end  may  enlarge 
and  form  a  false  socket,  while  the  other  end  forms  a  false  head,  both  contained 
in  a  capsule  of  dense  fibrous  tissue,  forming  a  sort  of  synovial  cavity,  or  false 
joint,  ("pseudo-arthrosis").  The  two  articulating  ends  generally  are  covered 
with  a  layer  of  dense  fibrous  tissue,  and  not  with  cartilage.  Sometimes,  when 
two  adjacent  bones  are  broken,  the  two  calluses  may  unite  to  form  one  single 
callus,  and  thus  the  two  bones  are  firmly  united  ("synostosis"). 

The  gross  appearance  about  a  fracture  corresponds  to  the  histological  condi- 
tion already  described.  The  swelling  of  the  soft  parts  which  appears  at  the  end 
of  a  few  hours  is  due  to  the  presence  of  an  inflammatory  exudate  in  the  injured 
soft  tissues.  The  blebs  and  bullae  which  may  appear  in  a  short  time  are  due  to 
elevation  of  the  superficial  layers  of  the  skin  by  the  fluid  exudate,  which  extends 
toward  the  surface.    If  the  injury  to  the  soft  tissues  is  severe,  the  overlying  skin 


PROCESSES  OF  REPAIR.  285 

may  be  discolored  bluish  at  once  from  deep  hsematoma,  or  it  may  become  black 
and  blue  after  a  few  days  from  disintegration  of  a  deep  hemorrhage,  with  diffu- 
sion of  blood  pigment.  As  the  exudate  diminishes  the  tissues  about  the  broken 
ends  become  thickened  from  cell  proliferation,  and  form  a  spindle-shaped  thick- 
ening (granulation-tissue  external  callus),  composed  of  ordinary  granulation 
tissue  and  of  granulation  tissue  arising  from  the  periosteum.  At  first,  this  callus 
is  firm  and  elastic,  but  not  bony.  After  about  two  weeks  the  callus  obviously 
becomes  harder  and  more  sharply  defined  (ossification  of  deep  portion  of  callus 
derived  from  periosteum).  At  this  time  the  fragments,  which  at  first  are  freely 
movable,  are  much  less  so,  and  move  only  under  strong  pressure.  After  a  vari- 
able number  of  weeks,  depending  upon  the  site  and  severity  of  the  fracture, 
mobility  entirely  disappears  (restoration  of  cortical  defect),  although  the  callus 
persists.  At  this  time  the  bone  is  strong  enough  to  bear  weight.  In  the  course 
of  months  the  callus  progressively  becomes  smaller,  and  finally  may  largely  or 
entirely  disappear  if  the  bones  are  in  perfect  position.  The  amount  of  callus 
which  persists  is  proportional  to  the  amount  of  deformitj^ 

There  are  certain  principles  of  treatment  of  fractures  which  depend  upon 
the  above-described  conditions. 

The  first  essential  is  to  secure  as  perfect  as  possible  approximation  of  the  frac- 
tured ends.  The  more  perfect  the  position  of  tlie  fracture,  the  smaller  the  exter- 
nal callus  and  the  shorter  the  time  required  for  completion  of  repair  of  the  bone. 
The  more  perfect  the  position,  the  less  is  the  interference  with  the  soft  tissues, 
and  in  all  fractures  it  is  to  be  remembered  that  there  is  injury  not  only  of  bone, 
but  of  soft  tissues.  As  regards  the  reduction  of  the  deformity,  it  should  be  borne 
in  mind  that  attempts  at  reduction  more  than  two  weeks  after  injury  are  likely 
to  give  poor  results.  During  the  earlier  stages  the  callus  is  soft  and  not  ossified. 
After  the  second  week  bone  formation  is  well  advanced,  the  ends  of  the  bone  are 
included  in  the  spindle-shaped  callus,  are  not  freely  movable  as  at  first,  and 
forcible  correction  causes  injury  to  the  newly  formed  bone  and  prolongation  of 
the  process  of  repair. 

Perfect  immobilization  also  is  essential.  The  less  the  callus  is  interfered 
with,  the  greater  is  the  rapidity  of  repair.  In  case  of  fracture  about  tendons  or 
into  the  articular  surfaces  of  joints,  other  mechanical  problems  enter  in,  so  that 
early  mobility  may  be  necessary  and  the  importance  of  rapid  ossification  may 
hold  a  secondary  place. 

Regeneration  of  bone.  As  has  been  said  already,  growth  in  diameter  of  bone 
is  dependent  upon  the  periosteum.  The  calcified  bone  itself  is  practically  inert. 
In  cases  in  which  there  has  been  extensive  destruction  of  bone,  advantage  may 
be  taken  of  the  power  of  the  periosteum  to  produce  new  bone  to  replace  loss. 

Oilier  has  shown  that  if  the  entire  shaft  of  a  healthy  bone  of  an  animal  be 
removed  subperiosteally,  leaving  the  periosteum  intact,  the  periosteum  will 
produce  new  bone  exactly  similar  in  outline  to  that  portion  of  the  bone  which 


286  .\iIERICAX  PRACTICE  OF  SURGERY. 

has  been  removed.  In  the  .same  way,  if  an  enthe  diaphysis,  e.g.,  of  a  long  bone, 
is  destroyed  by  disease,  e.g.,  by  acute  suppurative  infection  (acute  suppurative 
osteomyeUtis),  advantage  can  be  taken  of  this  fact  to  bring  about  a  complete 
regeneration  of  bone  to  replace  the  lost  tissue. 

The  vitality  of  calcified  bone  is  very  much  lower  than  that  of  the  surroimding 
periosteum.  Various  diseases  (osteomyelitis,  tuberculosis,  sarcoma)  may  cause 
the  death  of  a  considerable  portion  of  any  bone.  The  dead  bone  loses  its  power 
of  performing  its  function  of  supporting  weight.  In  that  case  the  periosteum 
surrounding  the  necrotic  bone  proliferates  to  form  new  bone  to  take  up  the 
weight-carrying  fimction.  The  dead  bone  persists  as  a  foreign  body,  while  the 
periosteum  forms  a  cylindrical  layer  of  new  bone,  of  a  structure  like  that  of  the 
bone  seen  in  the  external  callus,  about  the  dead  bone.  The  dead  bone  persists 
as  a  "sequestrum,"  surrounded  by  a  cylindrical  "  involucmm"  of  new  periosteal 
bone.  The  involucrum  at  first  is  soft,  like  the  early  external  callus,  and  contin- 
ues to  thicken  until  the  diameter  of  the  new  bone  equals  or  somewhat  exceeds 
the  diameter  of  the  original  shaft.  As  the  involucrum  becomes  older  it  becomes 
denser,  like  ordinary  cortical  bone,  which,  as  has  already  been  sho^-n,  has  very 
limited  power  of  repair.  The  sequestrum  usually  is  coimected  with  the  surface 
of  the  body  by  various  "sinuses,"  which  perforate  the  involucrum  at  various 
points.  At  any  of  these  stages,  i.e.,  early  necrosis,  early  periosteal  proliferation, 
or  in  the  stage  of  involucrum  and  sequestrum,  it  is  possible  to  take  advantage 
of  the  regenerative  power  of  the  periosteum  and  endostemn  to  bring  about  com- 
plete regeneration  of  bone. 

In  all  cases  it  first  is  necessary  to  remove  the  necrotic  bone,  which  acts  as  a 
foreign  body.  After  the  necrotic  bone  has  been  removed,  the  intact  periosteum 
should  be  approximated  so  as  to  bring  the  internal  surfaces  together  and  to 
leave  no  central  cavity.  The  growth  of  the  periosteum  is  peripheral,  and  new 
bone,  like  the  external  callus,  is  formed,  until  there  is  produced  a  shaft  of  perios- 
teal bone  which  slightly  exceeds  in  size  that  of  the  original  shaft.  As  the  bone 
becomes  harder  as  it  grows  older,  there  is  some  absorption  of  the  bone,  mitil  ulti- 
mately the  new  bone  is  of  the  same  size  as  the  original  shaft.  The  new  bone  at 
first  is  solid  bone  without  a  marrow  canal,  but  finally,  so  far  as  can  be  judged 
from  x-ray  pictures,  there  is  an  absorption  of  the  bone  in  the  centre  of  the 
shaft,  and  a  new  marrow  canal  is  formed.  The  notable  thing  about  this  proc- 
ess of  bone  regeneration  by  the  periosteum  is  that  the  new  bone  is  of  exactly 
the  same  shape  as  the  original  bone,  and  cannot  be  distinguished  from  it  even 
by  touch,  sight,  or  the  .r-ray.  This  suggests  that  the  shape  of  the  bones  of  the 
human  skeleton  is  due  to  two  causes— heredity  and  environment,  or  function. 
Hence  when  a  bone  is  removed  the  new  bone  which  is  formed  is  of  the  shape 
which  performs  function  to  the  best  advantage.  This  is  true  of  very  compli- 
cated bones,  and  even  of  complicated  joints  which  are  excised  subperiostealh^ 

In  some  cases  in  which  the  involucrum  is  old  it  has  limited  power  of  repair, 


PROCESSES  OF  REPAIR.  287 

and  in  such  cases  both  involucrum  and  sequestrum  must  be  removed,  to  give 
the  periosteum  a  chance  to  form  an  entirely  new  bone. 

F.  Repair  of  Muscle. 
After  a  wound  of  striated  muscle  there  comes,  as  in  all  injuries  of  the  soft 
tissue,  an  Lnflammatorj'  exudate.  In  the  cotirse  of  a  few  hours  there  arises  a 
new  growth  of  granulation  tissue  from  the  adjacent  connective  tissue  and 
also  a  peculiar  series  of  changes  in  the  muscle  itself.  Some  of  the  muscle  fibres 
next  to  the  wound  become  necrotic;  they  are  invaded  by  polynuclear  leuco- 
cytes and  endothelial  cells,  dissolved,  and  removed.  In  some  of  the  other 
muscle  fibres  there  occurs  an  increase  in  the  number  of  the  nuclei,  which  arise 
not  by  mitosis,  but  by  direct  nuclear  division.  These  nuclei  arrange  themselves 
in  the  ends  of  the  muscle  fibres,  and,  instead  of  having  a  mural  arrangement 
like  that  of  the  nuclei  in  normal  muscle  fibres,  are  situated  in  the  middle  of  the 
fibre.  The  fibre  itself  loses  its  strise,  and  becomes  more  or  less  fibrillated  longi- 
tudinally. The  greater  portion  of  these  cells  finally  disappear,  so  that  in  the 
granulation-tissue  scar  only  an  occasional  club-ended -fibre  is  left,  and  the  defect 
in  the  muscle  is  replaced  by  granulation  tissue,  which  ultimately  becomes  scar 
tissue.  If  the  ends  of  the  muscle  are  accurately  approximated,  the  scar  is  a 
small  one  and  Interference  with  muscle  fimction  is  slight.  If  the  ends  of  the 
muscle  are  widely  separated,  there  may  be  great  impairment  of  function. 

G.  Repair  of  the  Heart. 

In  wounds  of  the  heart  the  muscle  fibres  take  no  part  in  the  process  of  re- 
pair, but  the  defect  is  filled  by  granulation  tissue,  which  finally  forms  a  scar. 
Adhesion  to  the  pericardial  walls  is  common. 

H.  Repair  of  Blood-\'essels. 

Wounds  of  vessels  of  large  size  present  a  condition  somewhat  different  from 
that  of  woimds  of  other  tissues,  since  the  walls  contain  no  small  vessels  except 
in  the  adventitia  coat,  so  that  the  early  adhesion  of  the  edges  of  the  wound  is 
not  produced  by  an  inflammator}'  exudate  in  the  ordinary  sense  of  the  word, 
but  is  due  to  fibrin  which  arises  from  the  circulating  blood  in  the  vessel  itself. 
The  conditions  vary  somewhat  in  arteries  and  veins,  and  -with  the  character  of 
the  injur}-,  i.e.,  whether  there  is  complete  division  of  the  vessel,  or  a  lateral 
wovmd,  or  a  rupture  of  the  internal  coat. 

In  arteries  complete  division  of  the  wall  by  a  sharp  instrtmient  of  course  leads 
to  ■\.aolent  hemorrhage,  which  may  cause  death  in  a  short  time.  In  complete  di- 
vision of  an  arterj'  by  tearing  or  by  similar  \'iolence,  however,  extensive  hemor- 
rhage as  a  rule  does  not  take  place,  and  may  be  absent  even  in  clean  cuts,  because 
the  ends  of  the  vessel  retract  into  the  surrounding  tissues,  while  the  walls  of  the 
vessel  become  occluded  by  the  formation  of  a  clot,  composed  of  fibrin  derived 
from  the  blood  in  the  vessel  and  enclosing  red  blood  globules  and  a  few  leuco- 


288  AMERICAN  PRACTICE  OF  SURGERY. 

cytes.  In  wounds  in  the  wall  of  an  artery  the  hemorrhage  takes  place  into  the 
soft  tissues  about  the  point  of  injury,  and  coagulates,  so  that  finally  the  edges 
of  the  vessel  wound  are  sealed  together  by  a  layer  of  fibrin.  Within  the  lumen 
of  the  vessel  there  may  be  simply  a  thin  peripheral  clot  at  the  point  of  injury, 
covering  the  wound;  or  in  other  cases,  especially  if  the  endothelium  is  exten- 
sively injured,  a  thrombus  may  form,  of  such  size  as  to  occlude  the  vessel.  In 
ligature  of  a  vessel  which  is  completely  divided  there  is  formed,  at  the  point  of 
ligature,  a  clot,  the  size  of  which  is  variable,  depending  upon  the  rapidity  of  cir- 
culation, the  amount  of  injury  to  the  endothelium,  and  the  perfection  of  the 
asepsis. 

After  the  formation  of  the  thrombus  the  later  stages  are  like  those  of  any 
wound;  i.e.,  the  clot,  which  is  essentially- an  inflammatory  exudate,  in  which 
red  blood  globules  are  overwhelmingly  predominant,  becomes  converted  into 
organized  tissue.  If  the  clot  is  a  small  one,  situated  peripherally,  the  surface 
may  be  covered  by  newly  formed  endothelial  cells,  while  the  deeper  layers  of  the 
clot  are  replaced  by  newly  formed  connective  tissue  derived  from  the  media  and 
adventitia.  If  the  clot  is  of  large  size  and  completely  fills  the  lumen  of  the  ves- 
sel, the  surface  of  the  clot  toward  the  blood  stream  is  covered  with  endothelium 
growing  from  the  walls  of  the  vessel,  while  the  clot  itself  becomes  organized  by 
granulation  tissue.  The  lumen  of  the  vessel  beyond  the  point  of  obstruction 
undergoes  a  slow  diminution  in  size  through  an  obliterative  endarteritis. 

In  some  cases,  in  which  the  wound  in  the  vessel  is  a  lateral  one,  a  large  clot 
forms  about  the  point  of  injury  and  pushes  the  surrounding  soft  tissue.s  to  one 
side,  until  the  pressure  becomes  so  great  that  no  further  hemorrhage  takes  place. 
The  effused  blood  coagulates,  and  finally  the  periphery  may  become  organized  by 
granulation  tissue  arising  from  adjacent  connective  tissue.  In  some  cases  the 
centre  of  this  area  may  remain  patent  and  contain  fluid  blood,  connected  with 
the  circulating  blood  in  the  patent  vessel  through  the  interval  in  the  wall  made 
by  the  wound,  thus  forming  a  false  traumatic  aneurism. 

In  complete  division  of  veins  the  divided  ends  usually  are  filled  with  a  blood 
clot  which  becomes  covered  by  endothelium,  while  the  clot  itself  comes  to  be  re- 
placed by  dense  scar  tissue  derived  from  the  media  and  adventitia.  In  some 
cases,  however,  the  amount  of  terminal  clot  is  exceedingly  small.  In  case  of  a 
lateral  wound  of  a  large  vein,  it  often  is  possible  to  prevent  severe  hemorrhage 
by  ligaturing  the  wound  in  the  vessel.  In  that  case  the  inner  wall  of  the  veins  is 
puckered  by  ligature,  and  may  be  covered  with  a  thin,  peripherally  placed  clot, 
which  may  become  organized  without  the  formation  of  an  obstructing  and  ob- 
literating thrombus. 

In  all  lateral  wounds  of  vessels  absolutely  perfect  asepsis  is  essential  if  one 
expects  to  obtain  healing  without  complete  thrombosis  and  obstruction.  The 
presence  of  even  a  slight  amount  of  infection  is  practically  certain  to  cause  suffi- 
cient injury  to  the  endothelium  to  produce  complete  obstruction.    In  suturing 


PROCESSES  OF  REPAIR.  289 

of  vessels  it  is  said  that  the  projection  of  perfectly  aseptic  sutures  uito  the  lumen 
of  the  vessel  through  the  endothelium  does  not  necessarily  produce  thrombosis, 
but  that  in  many  cases  the  sutures  are  very  early  covered  with  new  endothelium. 

I.  Peripheral  Nerves. 

Section  or  destructive  injury  of  a  peripheral  nerve  causes  an  immediate 
traumatic  local  degeneration  of  the  nerve  at  the  point  of  injury.  This  is  fol- 
lowed by  a  degeneration  throughout  the  extent  of  the  nerve  peripheral  to  the 
point  of  injury,  and  a  degeneration  of  the  fibres  proximal  to  the  point  of  in- 
jury, extending  no  farther  than  the  first  few  nodes  of  Ranvier.  There  also 
occur  changes  in  the  cells  of  origin  of  the  degenerated  nerves,  resulting  in  an 
effacement  of  the  granular  structure  of  the  nerve  cell  body,  with  displacement 
of  the  cell  nucleus  to  the  periphery  of  the  cell — the  so-called  "axonal  reaction" 
of  Nissl. 

Following  the  degeneration  occur  regenerative  changes  in  the  nerve,  which 
may  lead  to  a  restoration  of  function.  The  eictent  to  which  this  regeneration 
may  occur  depends  somewhat  upon  the  amount  of  injury  to  surrounding  soft 
parts.  If  the  injury  is  one  which  destroys  the  integrity  of  the  nerve  fibre,  with- 
out destroying  the  continuity  of  the  nerve  sheath — e.g.,  crushing  injuries — the 
regeneration  of  the  nerve  is  more  rapid  and  certain.  If  the  nerve  is  cut  across 
and  the  ends  are  sutured  together,  regeneration  is  more  likely  to  occur  than  it  is  if 
the  ends  retract  and  become  widely  separated,  or  if  suppuration  occurs  so  that 
the  ends  are  separated  by  a  wide  zone  of  granulation  tissue.  If  the  peripheral 
end  of  a  nerve  is  entirely  removed,  as,  e.g.,  in  an  amputation,  a  peculiar  partial 
regeneration  of  the  proximal  portion  may  occur,  resulting  in  an  "amputation 
neuroma." 

After  the  receipt  of  an  injury  there  comes  a  traumatic  degeneration  of  the 
nerve  in  the  immediate  vicinity  of  the  injury.  The  amount  of  this  degeneration 
depends  upon  the  character  of  the  injury,  being,  e.g.,  slight  in  a  clean-cut  wound 
and  more  extensive  after  a  crush.  Immediately  after  this  change  there  comes 
a  secondary  ("paralytic")  degeneration  of  the  nerve,  extending  in  either  direc- 
tion from  the  point  of  injury.  On  the  central  side  of  the  injury  the  degeneration 
extends  upward  to  the  nearest  nodes  of  Ranvier.  On  the  peripheral  side  the 
degeneration  extends  throughout  the  entire  extent  of  the  nerve. 

The  degenerative  changes  produce  a  fragmentation  and  fibrillation  of  the 
axis  cylinder,  and  a  fragmentation  of  the  medullary  sheath.  Very  early  there 
also  arises  marked  proliferation  of  the  cells  in  the  sheath  of  Schwann. 

The  regenerative  process  begins  after  the  degenerative  process.  It  is  difficult 
to  say  just  how  the  new  axis  cylinders  are  produced,  there  being  dispute  upon 
this  point;  but  the  new  axis  cylinders  extend  gradually  into  the  peripheral  end. 
Most  observers  believe  that  the  process  of  growth  is  like  that  in  embryonal 
development,  i.e.,  there  is  a  constant  peripheral  growth.    Others  believe  that  the 


293  AMERICAN  PRACTICE  OF  SURGERY. 

new  formation  is,  partly  at  least,  the  result  of  activity  of  cells  in  the  sheath  of 
Schwann.  As  a  practical  matter,  the  new  fibres  in  the  adult  always  arise  from 
the  central  stump  and  extend  peripherally  along  the  track  of  the  original  nerve. 

The  new  fibres,  as  they  arise  from  the  central  stmnp,  tend  to  split  into  bun- 
dles of  small  neuro-fibrils,  of  which  the  original  nerve  is  supposed  to  be  com- 
posed. The  direction  of  the  new  fibres  may  be  modified  by  various  mechanical 
obstructions,  and  also  by  an  apparent  attraction  of  the  distal  nerve  remnant  for 
the  proximal  nerve  fibres.  The  fibres  at  first  grow  in  the  interstices  between  the 
cells  of  the  scar  ("neurotization  of  the  scar"),  which  lies  between  ends  of  the 
nerve.  If  the  scar  between  the  ends  is  too  dense,  the  new  fibres  may  grew  into 
the  tissues  in  various  directions,  and  never  may  be  able  to  get  into  contact  with 
the  peripheral  stump.  In  such  cases  no  restoration  of  nerve  fimction  takes 
place.  The  tendency  of  the  proximal  axones  to  join  the  peripheral  stump  can 
be  favored  by  various  mechanical  means,  e.g.,  by  the  introduction  of  catgut 
sutures  or  hollow  tubes,  along  the  tract  of  the  nerve,  or  by  means  of  neuro- 
plastic  flaps.  Regeneration  is  obstructed  by  secondary  infection  with  excessive 
formation  of  granulation  tissue. 

The  rate  of  regeneration  varies  somewhat,  but  is  approximately  at  the  rate 
of  1  mm.  per  day. 

J.   Central  Nervous  System. 

As  regards  regeneration  or  repair  of  injuries  to  the  central  nervous  system, 
while  theoretically  possible  to  a  very  slight  degree,  the  amount  of  regeneration 
is  so  slight  as  to  be  of  no  surgical  importance.  The  cause  of  the  lack  of  power 
of  central  nerves  to  regenerate  is  obscure,  but  it  is  claimed  to  be  due  to  the  fact 
that  the  central  nerve  fibres  do  not  possess  a  sheath  of  Schwann,  which  is  es- 
sential in  some  way  to  the  new  formation  of  axis  cylinders,  and  also  to  the  fact 
that  the  neuroglia  fibrils  offer  a  mechanical  obstruction  to  the  advance  of  nerve 
fibres. 


TUMORS  AND  TUMOR  FORMATION. 

Bij  ALBERT  G.  NICHOLLS,  M.D.,   CM.,    Montreal,  Canada. 


Definition. — The  term  tumor  in  its  literal  sense  means  swelling.  Any  swell- 
ing, therefore,  irrespective  of  its  cause,  might  be  called  a  tumor.  Swelling,  how- 
ever, as  we  know,  is  merely  an  external  symptom  and  may  be  brought  about  by 
a  great  variety  of  causes,  such  as  congestion,  oedema,  hemorrhage,  inflammatory 
infiltration,  deposits  of  various  kinds,  and  the  new  formation  of  tissue.  All  the 
conditions  mentioned  have  this  in  common,  that  the  part  is  enlarged.  In  the  old 
days,  before  the  publication  of  "Die  krankhaften  Geschwiilste, "  the  wildest 
speculations  were  rife  as  to  the  causes  of  pathological  phenomena,  so  that  we  are 
not  surprised  that  many  essentially  unlike  conditions  should  have  been  confused 
together.  The  word  "tumor"  was  conveniently  broad  and  noncommittal  and, 
like  charity,  was  made  to  cover  a  multitude  of  sins.  It  is  curious  how  tradi- 
tional modes  of  expression  will  persist,  for  even  yet  we  not  infrequentl}^  speak  of 
tumor  albus,  the  ivhite  swelling  or  tumor,  when  we  mean  tuberculous  synovitis 
with  effusion.  The  appearance,  in  1863,  of  Virchow's  epoch-making  work,  with 
its  insistence  on  the  doctrine  of  what  is  commonly  known  as  the  "  cellular  path- 
ology," laid  the  foundation  of  and  pointed  the  way  to  a  more  adequate  concep- 
tion of  pathological  processes,  particularly  cell  proliferation.  From  this  time 
modern  pathology  may  be  said  to  date.  With  the  improvements  in  microscop- 
ical technique  many  additional  facts  have  been  recorded,  and  while  many  of 
Virchow's  conclusions  have  been  shown  to  be  partial  and  even  erroneous,  the 
fundamental  principles  which  he  laid  down  have  been  confirmed  and  strength- 
ened. The  result  has  been  to  restrict  the  term  tumor  to  pathological  new-forma- 
tions of  tissue.  But  here  a  difficulty  was  soon  encountered,  a  difficulty  that  cannot 
be  said  to  be  entirely  cleared  up  even  yet.  This  is,  that  certain  inflammatory 
processes  give  rise  to  local  swellings  and  some  of  the  other  phenomena  that  we 
usually  associate  with  the  idea  of  a  tumor.  Thus,  in  typhoid,  malaria,  and  some 
other  infectious  diseases  the  spleen  may  be  greatly  enlarged  as  a  result  of  prolifer- 
ation of  tissue.  The  most  notable  example  is,  however,  to  be  found  in  the  so- 
called  "infective  granulomata."  In  tuberculosis,  syphilis,  actinomycosis,  lep- 
rosy, and  some  forms  of  animal  parasitism,  we  get  localized  nodules,  associated 
often  with  great  proliferation  of  cells,  with  central  necrosis,  which  tend  to  spread 
and  may  even  give  rise  to  similar  growths  elsewhere.  The  resemblance  to  a  tu- 
mor is  therefore  striking.  More  thorough  investigation  has  served  to  draw  a  dis- 
tinction between  cell  proliferation,  due  to  infective  and  other  forms  of  irritative 

291 


292  AMERICAN  PRACTICE  OF  SURGERY. 

inflammation,  and  tissue  neoplasia  due  to  none  of  these  causes.  What,  then,  con- 
stitutes the  difference  between  an  inflammatory  neoplasm  or  granuloma  and  a 
tumor,  using  the  latter  term  in  its  more  restricted  modern  sense?  An  inflamma- 
tory granuloma  can  be  traced  to  a  definite  cause,  usually  some  micro-organism;  it 
is  reactive  and  its  purpose  benign,  in  so  far  as  it  is  an  attempt  to  neutralize  the 
effect  and  repair  the  damage  caused  by  the  invading  element ;  the  process  goes  on 
only  so  long  as  the  cause  is  operative,  and  ceases  when  it  has  come  to  an  end.  A 
true  tumor,  on  the  other  hand,  is  a  new  formation  of  tissue,  due  to  no  demon- 
strable cause;  the  vegetative  power  of  the  cells  composing  it  is  excessive  and 
appears  to  be  inherent ;  the  growth  takes  place  Avithout  regard  to  the  neighbor- 
ing structures  and  is,  therefore,  a  law  unto  itself;  finally,  it  subserves  no  useful 
purpose  in  the  body.  We  may,  therefore,  with  Thoma,  define  a  tumor  shortly  as 
an  autonomous  or  indepeiident  neiv-growth.  The  peculiar  features  of  tumors  are 
the  following:  (1)  The  majoritj'  begin  at  some  one  point  in  an  organ  and  subse- 
quently spread  to  neighboring  parts.  (2)  They  reproduce  with  more  or  less 
modification  the  tissues  from  which  they  spring.  (3)  They  differ  in  physiologi- 
cal function  from  the  part  in  which  they  are  fovuid.  (4)  They  cause  pressure- 
atrophy  and  dislocation  of  the  adjacent  structures,  or,  again,  lead  to  destructive 
infiltration.  (5)  They  are  particularly  liable  to  retrogressive  changes.  (6)  The 
tumor  cells  in  many  instances,  when  transplanted  to  distant  parts,  give  rise 
to  secondary  tumors  resembling  in  properties  and  appearance  the  original 
growth. 

Etiology. — Notwithstanding  the  fact  that  of  late  years  our  information  in  re- 
gard to  tumors  and  tumor  formation  has  been  steadily  increasing,  the  question  of 
etiology  still  remains  largely  an  unsolved  problem.  We  know  to  some  extent  the 
general  laws  governing  the  proliferation  of  tissue.  We  are  familiar  with  the  ap- 
pearance and  minuter  structure  of  the  various  tumors.  We  can  apprehend 
in  some  degree  their  mode  of  origin  and  method  of  extension.  We  have  made 
some  progress  in  differentiating  the  various  forms.  But,  when  all  is  said  and 
done,  it  must  be  confessed  that  the  essential  cause  has  up  to  the  present  eluded 
discovery.  We  are  still  puzzling  over  the  question.  What  is  the  force  that  in 
the  first  instance  determines  the  cell  proliferation  in  tumors?  I  do  not  propose 
here  to  enter  the  arena  of  controversy  and  discuss  the  various  theories  that 
have  been  advanced  to  explain  tumor  formation.  This  has  been  done  very  fully 
and  competently  in  another  portion  of  this  work.  I  will,  therefore,  content 
myself  simply  with  drawing  attention  to  a  few  points  that  are  of  considerable 
practical  importance. 

Leaving  for  the  moment  the  benign  tumors  out  of  consideration,  the  surgeon  is 
confronted  by  two  undeniable  facts.  Carcinomata  develop  most  frequently  at 
the  so-called  ostia  of  the  various  portions  of  the  alimentary  tract,  the  lips,  tongue, 
cardia  and  pylorus  of  the  stomach,  the  ileo-c£ecal  valve  and  anus;  in  ducts  and 
hollow  viscera,  as,  for  instance,  the  bile  ducts,  the  gall  bladder,  theurinar}'  bladder, 


TUMORS  AND  TUMOR  FORMATION.  293 

and  the  uterus.  Tissues  in  all  these  places  are  subject  to  considerable  meclian- 
ical  and  other  irritation.  We  may  conclude,  therefore,  that  the  influence  of  ex- 
ternal traumatism,  using  that  term  in  its  widest  sense  to  include  irritation  from 
mechanical,  thermal,  chemical,  and  infective  causes,  is  by  no  means  unimportant. 
A  great  deal  of  evidence  has  accumulated  to  support  this  position.  Carcinomata 
have,  for  instance,  been  known  to  develop  in  the  cicatrices  of  burns,  in  the 
neighborhood  of  setons,  in  the  bases  of  chronic  ulcers  and  lupus  patches,  and 
at  the  orifices  of  sinuses.  The  irritation  of  soot  (sweep's  cancer),  tar,  and 
paraffin  in  the  clothing  occasionally  sets  up  carcinoma  of  the  scrotum.  Epithe- 
liomata  of  the  lip  and  tongue  are  not  infrequently  associated  with  irritation 
of  the  part  by  a  pipe;  carcinoma  of  the  biliary  passages  is  often  accompa- 
nied by  cholelithiasis;  a  chronic  ulcer  of  the  stomach  may  become  malignant. 
Again,  constant  or  repeated  irritation  may  convert  a  benign  growth  into  a  malig- 
nant one.  Yet,  when  we  consider  how  often  irritation  of  the  same  kind  and  in- 
tensity fails  to  produce  tumor  growth,  we  have  to  admit  that  irritation  can  only  be 
the  exciting  cause,  and  that  at  the  back  of  it  all  is  some  unknown  force  that  deter- 
mines the  fact  of  cell  proliferation. 

The  second  point  is,  that  many  tumors  arise  in  parts  of  the  body  where  there  are 
transition  of  epithelium,  complicated  infoldings  of  tissues,  and  the  closure  of  devel- 
opmental fissures.  At  such  places  the  cell  equilibrium  appears  to  be  unstable. 
As  examples  may  be  cited :  cystic  tumors  and  epitheliomata  occurring  in  the  neck 
in  parts  where  normally  epithelium  does  not  exist,  in  consequence  of  defective 
closure  of  the  branchial  clefts ;  hypernephromata ;  the  heterologous  tumors,  such  as 
chondromata  of  the  mamma,  parotid,  and  testis ;  dermoid  cysts  of  the  ovary  and 
testis,  and  other  teratoid  growths.  In  many  cases  it  can  be  shown  that  the 
neoplasm  originates  in  misplaced  embryonic  cells  or  "  rests."  With  the  increase  in 
our  knowledge  of  tumors,  this  class  of  growths  has  been  greatly  enlarged,  and  the 
"  developmental"  theory  of  tumor  formation  has  probably  the  greatest  number  of 
adherents  among  pathologists.  None,  however,  give  it  the  wide  application  that 
Cohnheim  has  done.  Not  a  few  tumors  have  not  as  yet  been  satisfactorily 
accounted  for  on  this  basis,  and  in  any  case,  even  were  the  theory  universal, 
the  ultimate  cause  of  the  neoplasia  remains  unknown. 

The  Gross  Appearance  of  Tumors. — Tumors  vary  greatly  in  size.  Some  are 
microscopic,  others  may  exceed  in  weight  the  individual  in  whom  they  are  found. 
The  shape  is  also  variable,  being  in  large  part  governed  by  external  conditions. 
Tumors  on  free  surfaces  grow  in  all  directions  and  tend  to  assume  a  rounded  form. 
Those  occurring  in  closed  cavities  accommodate  themselves  to  the  space  in  which 
they  lie.  Tumors  may,  therefore,  be  tuberous  or  nodular,  lobulated,  fungoid, 
polypoid,  papillary,  sessile,  or  diffuse. 

In  regard  to  consistence,  some  are  soft,  friable,  juicy,  and  brainlike;  others 
firm,  hard,  fibrous,  or  stony.  Differences  in  consistence  and  texture  may  be 
found  in  different  parts  of  the  same  tumor. 


294  MIERICAN  PRACTICE  OF  SURGERY. 

Most  new  growths  are  white  or  gra3'ish-white  in  color.  Some,  however,  are 
reddish,  yellow,  brown,  green,  or  even  black.  As  a  rule,  the  substance  of  a  tumor 
is  sufficiently  unlike  that  of  the  part  in  which  it  is  found  to  render  its  detec- 
tion easy.  Yet  some,  like  the  gliomata  of  the  central  nervous  system,  are  with 
difficulty  distinguished  from  the  healthy  tissues. 

The  benign  neoplasms  are  provided  with  a  more  or  less  complete  capsule, 
while  the  malignant  ones  are  badly  defined  and  infiltrating  in  character. 

On  section,  tumors  may  present  the  features  above  mentioned,  but  may  also 
in  parts  show  evidences  of  retrogressive  processes,  fatty  degeneration,  caseation, 
liquefaction,  hemorrhagic  extravasation,  colloid  transformation,  or  even  sup- 
puration. 

The  Classification  of  Tumors. — There  are  few  subjects  in  the  realm  of  pathol- 
ogy more  fraught  with  difficulty  than  this.  For,  as  in  so  many  other  branches  of 
science,  so  here,  improved  methods  of  investigation  and  more  extensive  informa- 
tion have  resulted  in  the  replacement  of  the  crude  ideas  formerly  in  vogue  by 
much  more  complex  conceptions.  Yet  we  cannot  say  that  the  steadily  increas- 
ing knowledge  we  are  gaining  from  day  to  day  with  regard  to  the  structure 
and  histogenetic  development  of  new  growths  has  been  attended  by  a  corre- 
sponding advance  in  our  views  as  to  the  true  nature  of  these  formations.  Various 
classifications,  as  numerous  as  the  definitions  of  what  constitutes  a  tumor,  have 
been  proposed,  all  of  which  have,  in  the  light  of  modern  investigations,  been 
proved  to  be  faulty  in  one  or  more  important  particulars.  Four  methods  of 
classification  appear  to  be  possible:  (1)  According  to  etiology,  (2)  according  to 
clinical  peculiarities,  (3)  according  to  morphology  and  histogenetic  development, 
and  (4)  on  the  basis  of  embryological  differentiation. 

A  classification  on  etiological  principles,  were  it  possible,  would  be  strictly 
scientific,  but  it  is  hardly  necessary  to  say  that,  in  view  of  the  obscurity  that 
enwraps  the  question  of  the  essential  cause  of  neoplastic  growth,  such  a  classifi- 
cation is  not  at  present  practicable,  nor,  indeed,  in  my  opinion,  is  it  likely  to  be 
so  useful  as  some  others  that  might  be  devised.  We  may,  then,  dismiss  this  part 
of  the  subject  without  more  ado. 

The  clinical  behavior  of  tumors  enables  us  to  lay  down  certain  broad  gen- 
eralizations that  are  unquestionably  of  value  and  convenience  in  any  consider- 
ation of  the  nature  of  neoplastic  growth.  I  refer  to  the  common  division  of 
neoplasms  into  henign  and  malignant.  A  benign  tumor  may  in  general  terms  be 
defined  as  a  slowly  growing  tumor,  often  encapsulated,  which  does  not  tend  to 
invade  neighboring  structures,  does  not  produce  secondary  growths  in  distant 
parts,  and  produces  its  symptoms  chiefly  by  its  bulk.  A  malignant  tumor,  on 
the  other  hand,  is  usually  rapid  in  its  growth,  invades  and  destroys  the  adjacent 
tissues,  is  apt  to  form  secondary  growths  in  other  organs,  tends  to  necrose  or  ul- 
cerate, frequentl)'  recurs  after  removal,  and,  finally,  produces  certain  grave  con- 
stitutional disturbances  commonly  included  under  the  term  cachexia.    This  class- 


TUMORS  AND  TUMOR  FORMATION.  295 

ification,  while  to  a  certain  extent  it  subserves  a  useful  clinical  purpose,  is  open 
to  the  objection  that  it  lays  stress  on  a  somewhat  inconstant  feature  of  tumors  as 
a  means  of  differentiation,  to  the  exclusion  of  much  more  fundamental  characters. 
As  a  consequence,  tumors  that  have  little  in  common  in  point  of  structure  are 
brought  into  the  same  category.  We  know,  for  example,  that  chondromata  and 
adenomata,  both  of  which  are  usually  regarded  as  benign  growths,  may,  excep- 
tionally, give  rise  to  secondary  growths,  which,  however,  do  not  markedly  tend 
to  infiltrate.  In  other  words,  they  occasionally  exliibit  a  limited  tendency  to 
malignancy.  Again,  certain  tumors,  notably  pigmented  moles,  may  be  practi- 
cally identical  in  histological  structiu'e  with  melanotic  sarcomata  and  carcino- 
mata,  and  yet  may  persist  for  years  without  taking  on  excessive  growth,  though 
they  may  do  so  in  time,  when  irritated.  Their  malignancy  is,  as  it  were,  latent. 
Their  place,  therefore,  seems  to  be  intermediate  between  benign  and  malignant 
growths.  The  classification  in  question  is,  in  fact,  too  wide  to  be  accurate  and  is, 
moreover,  as  artificial  and  unscientific  as  the  Linnsean  classification  of  plants. 

Much  more  can  be  said  in  favor  of  the  grouping  of  tumors  on  a  morpho- 
logical basis,  and  this  is  the  method  which,  in  some  shape  or  other,  is  the  most 
popular  among  pathologists  at  the  present  time. 

With  the  advent  of  the  newer  "Cellular  Pathologie"  it  became  possible  for 
the  first  time  to  attempt  the  classification  of  new  growths  on  a  rational  basis, 
and  with  the  improvements  in  technicjue,  and  the  enormous  increase  in  knowl- 
edge that  has  resulted  therefrom,  the  principles  originally  enunciated  by  Virchow 
have  been  in  a  large  measure  placed  upon  a  solid  substratum  of  fact. 

Virchow,  among  other  things,  as  a  result  of  his  investigations,  pointed  out  that 
certain  tumors  conform  more  or  less  accurately,  so  far  at  least  as  their  structure 
is  concerned,  with  normal  forms  of  tissue,  while  others  show  deviations,  chiefly 
in  the  direction  of  being  more  cellular.  The  latter  for  the  most  part  are  malig- 
nant in  nature  with  all  the  peculiarities  which  this  implies.  According  to  Vir- 
chow, then,  we  can  recognize  two  main  groups,  the  cellular  tumors  and  the  less 
cellular  tumors.  In  the  former,  the  component  cells  are  greatly  increased  as  com- 
pared with  the  corresponding  normal  tissues.  This  includes  forms  which  are  now 
termed  sarcoma  and  carcinoma.  The  latter  group  was  subdivided  by  Virchow 
into  the  histioid  and  organoid  tumors.  Histioid  tumors  are  made  up  for  the  most 
part  of  cells  resembling  one  of  the  normal  tissues,  while  organoid  tumors  are  com- 
posed of  several  tissues,  normal  in  regard  to  their  structure,  and  arranged  after 
the  fashion  of  an  organ.  This  classification  is  important  chiefly  because  it  clearly 
indicates  the  agreement  between  normal  and  autonomous  tissue  formation. 
More  complete  study  has  shown,  as  Thoma  has  pointed  out,  that  no  tumor  con- 
sists of  only  one  tissue.  All,  for  example,  are  provided  with  blood-vessels,  and 
many  of  them  with  nerves,  while  at  some  part  there  is  invariably  a  certain 
amount  of  connective  tissue  to  be  found.  Hence,  histioid  tumors  always  have 
an  arrangement  similar  to  that  of  an  organ,  if  it  be  only  to  a  limited  degree.  The 


296  AMERICAN   PRACTICE   OF  SURGERY. 

distinction  between  histioid  and  organoid  tumors  may  properly,  therefore,  be 
allowed  to  drop. 

From  somewhat  different  considerations,  Virchow  again  recognized  two  great 
classes  of  tumors:  the  homoplastic  growths,  which  in  structure  closely  resemble 
the  normal  tissues  from  which  they  arise,  and  the  heteroplastic,  which  deviate 
widely  from  the  normal.  More  complete  investigations  have  shown,  however, 
that  perfect  homoplasia  never  really  exists,  and  that  all  true  tumors — and  in  this 
category  we  would  not  of  course  place  ordinary  tissue  hypertrophies — are  to  a 
greater  or  less  degree  heteroplastic. 

If  it  be  granted — and  for  these  conclusions  we  have  ample  proof — that  every 
cell  or  group  of  cells  is  derived  from  some  pre-existing  cell  ancestor,  and,  as  a 
corollary  to  this,  that  every  new  growth  has  its  prototype  in  a  normal  tissue,  then 
it  is  possible  to  classify  tumors  according  to  their  origin,  and  this  is  the  funda- 
mental principle  underlying  what  may  be  called  the  embryological  method  of 
classification. 

It  is  now  well  recognized  that  at  a  very  early  period  in  the  development  of  the 
embryo  the  almost  entirely  undifferentiated  cells  of  the  morula  become  arranged 
into  two  layers,  the  primitive  epiblast  and  hypoblast,  indicating  the  future  epi- 
derm  and  endoderm.  Very  soon  the  hypoblast,  or  innermost  of  the  two  primitive 
layers,  proliferates  and  gives  rise  to  a  mass  of  cells,  the  mesoblast,  which  lies  inter- 
mediate between  the  primitive  epiblast  and  hypoblast.  To  these  three  primitive 
layers,  epiblast,  mesoblast,  and  hypoblast,  can  be  traced  the  origin  of  all  the 
tissues  of  the  body.  This  being  so,  it  is  quite  logical  to  classify  tumors  in  the 
same  way,  and  this  in  fact  has  been  done,  notably  by  Waldeyer,  who  recognized 
tumors  of  epiblastic,  mesoblastic,  and  hypoblastic  derivation.  It  was  quickly 
found,  too,  that  epiblastic  and  hypoblastic  tumors  presented  many  striking 
points  of  similarity,  so  that  they  have  now  come  to  be  classed  together  under  the 
designation  of  tumors  "of  epithelial  type,"  as  contradistinguished  from  those  of 
mesoblastic  origin  and  "connective-tissue  type."  Thus,  both  on  embryological 
and  on  histological  grounds,  we  can  recognize  two  great  classes  of  tumors, 
apparently  sharply  differentiated  the  one  from  the  other,  those  of  mesoblastic 
origin  and  connective-tissue  type,  and  those  of  epithelial  and  glandular  origin 
and  of  epithelial  and  glandular  type.  This  is  the  most  popular  classification 
among  pathologists  at  the  present  time,  is  withal  practical  and,  so  far  as  it  goes, 
scientific.     Both  groups  may  be  divided  into  benign  and  malignant. 

The  benign  connective-tissue  growths  include  the  'fibroma,  myxoma,  lipoma, 
myoma,  chondroma,  osteoma,  glioma,  neuroma,  ha:mangioma,  lymphangioma. 

The  malignant  are  the  various  forms  of  sarcoma,  and  the  malignant  myomata. 

The  benign  tumors  of  epithelial  type  include  the  papilloma,  the  adenoma,  and 
cystadenoma. 

The  malignant  are  the  malignant  adenoma,  the  adeno-carcinoma,  carcinoma, 
and  epithelioma. 


TUMORS  AND  TUMOR  FORMATION.  297 

To  these  may  be  added  certain  mixed  forms,  consisting  both  of  epithehal  and 
of  connective-tissue  elements,  one  or  other  of  which  may  predominate.  Such  are 
the  papillary  fibroma,  the  papillary  cystadenoma,  the  ade^io- fibroma,  and  similar 
growths. 

It  may  be  remarked  en  passant  that  the  majority  of  epithelial  tumors  are,  in 
a  sense,  of  mixed  type,  for,  with  the  possible  exception  of  the  epithelioma,  most 
of  them  show  evidences  in  some  part  or  other  of  a  new  formation  of  fibrous  tissue. 

The  objections  that  have  been  brought  forward  to  this  mode  of  classification 
are  that  there  are  not  a  few  cases  to  be  met  with  which  do  not  fit  into  the  scheme. 
The  first  great  type  embraces  the  tumors  of  mesoblastic  origin  and  connective- 
tissue  type.  Now,  the  gliomata,  which  are  of  connective-tissue  type,  and,  there- 
fore, are  generally  classed  with  the  fibromata  and  other  tumors  of  this  group, 
are  not  mesoblastic,  but  epiblastic.  To  include  them  with  the  fibromata  and 
homologous  growths  is,  to  say  the  least,  artificial.  Again,  certain  tumors  of  the 
kidney,  suprarenal,  ovaries,  testis,  and  uterus,  while  histologically  of  epithelial 
type,  in  that  resembling  the  carcinomata,  are  really  of  mesoblastic  origin.  If, 
therefore,  we  are  to  preserve  the  embryological  method  of  classification,  some 
method  must  be  devised  of  grouping  like  with  like,  and  bringing  histological 
structure  into  harmony  with  embryological  derivation. 

This  has  been  attempted  by  Prof.  J.  G.  Adami  in  an  important  contribution 
to  the  subject,  entitled  "On  the  Classification  of  Tumors"  (Journal  of  Pathol- 
ogy and  Bacteriology,  June,  1902).  He  recognized  that  in  early  fcetal  exist- 
ence we  have  two  differentiations  of  the  primitive  cell  layers,  leading  to  the 
production  of  two  sets  of  tissues.  One  he  calls  lepidic  or  lining-membrane  tis- 
sues; the  other,  hylic  or  pulp  tissues.  The  lepidic  tissues  form  the  lining  endo- 
thelium of  blood-vessels,  lymphatics,  serous  membranes,  and  the  acini  of  various 
glands.  They  have  this  in  common,  that  there  is  an  absence  of  stroma  between 
the  members  of  the  cell  groups.  The  pulp  tissues  are  composed  of  an  intercel- 
lular ground  substance,  either  homogeneous  or  fibrillated,  separating  the  specific 
cells  of  the  tissue,  and  constitute  the  supporting  stroma. 

On  this  basis,  and  in  accordance  with  the  principles  just  enunciated,  Adami 
would  classify  blastomatous  tumors  after  the  following  scheme : 

I.  LEPIDOMATA  OR  "RIND"  TUMORS. 
A.  Primary  Lepidomata. 

1.  Epilepidomata. 
Tumors  whose  characteristic  constituents  are  overgrowths  of  tissues,  derived 
directly  from  the  epiblastic  lining  membranes,  or  true  epiblast. 

(a)  Typical. — Papilloma,  epidermal   adenomata  (of  sweat,  salivary,   seba- 

ceous, and  mammary  glands,  etc.). 

(b)  Atypical. — Epithelioma  proper,  carcinoma  of  glands  of  epiblastic  origin. 


298  AMERIC.IX  PRACTICE  OF  SURGERY. 

2.  Hypolepidomata. 

(a)  Typical. — Adenoma  and  papilloma  of  digestive  and  respirator}^  tracts, 

thjToid,  pancreas,  liver,  bladder,  etc. 

(b)  Atypical. — Carcinoma  developing  in  the  same  organs  and  regions. 

B.     Secondary  Lepidomata. 

3.  ilesolepidomata. 

Tumors  whose  characteristic  constituents  are  cells  derived  in  direct   descent 
from  the  persistent  mesotheliiwi  of  the  embryo. 

(a)  Typical. — Adenoma  of  kidney,  testicle,  ovary,  urogenital  ducts;   ade- 

noma of  uterus  and  prostate ;  adenomas  originating  from  the  serous 
membranes,  "mesothelioma"  of  pleurae,  peritoneum,  etc. 

(b)  Atypical. — Cancer  of  the  above-mentioned  organs:  squamous  endothe- 

lioma, so  called,  of  serous  surfaces ;   epithelioma  of  vagina. 

4.  Endothelial  Lepidomata. 
Tumors  originating  from  the  endothelium  of  the  blood-  and  lymph-vessels; 
endothelioma,  perithelioma. 

II.  HYLOMATA  OR  "PULP"  TUMORS. 
1.  Epihylomata. 
Tumors  whose  characteristic  constituents  are  overgrowths  of  tissues  derived 
from  the  embryonic  pulp  of  epiblastic  origin. 

(a)  Typical. — True  neuroma,  glioma. 

(b)  Atypical. — "  Glio-sarcoma. " 

2.  Hypohylomata. 

Tumors  derived  similarly  from  embryonic  pulp  of  hypoblastic  origin.     (?)  Chor- 
doma. 

3.  Mesohylomata. 

A.  Mesenchymal  Hylomata. — Derived  from  tissues  originating  from  the  per- 
sistent mesoblastic  pulp  or  mesenchjine. 

(a)  Typical. — Fibroma,  lipoma,  chondroma,  osteoma,  myxoma,  leio-myoma. 

(b)  Atypical. — Sarcoma  (derived  frommesenchymatous  tissues),  with  its  vari- 
ous subdivisions,  fibro-sarcoma,  spindle-cell  sarcoma,  oat-shape-cell  sarcoma, 
chondro-sarcoma,  osteo-sarcoma,  myxo-sarcoma,  melanotic  sarcoma,  etc. 

B.  Mesothelial  Hylomata. — Tumors  which  are  overgrowths  similarly  of  tis- 
sues derived  from  embryonic  pulp  of  definitely  mesothelial  origm. 

Rhabdomyoma. 

It  will,  perhaps,  be  an  aid  to  the  proper  understanding  of  a  somewhat  abstruse 
part  of  the  subject,  and  make  clear  the  virtues  of  the  new  classification,  if  we 


TOIORS  AND  TUMOR  F0R:\IATI0N.  299 

enumerate  the  various  tissues  and  structures  derived  from  the  primitive  germ 
layers. 

I.  EpIBLASTIC    STRrCTURES. 

The  skin  and  its  appendages,  epidermal  glands,  hair,  nails,  enamel  of  the 
teeth,  the  lens  of  the  eye,  the  epithelium  of  the  cornea,  olfactory  organ,  the  mem- 
branous labyrinth  of  the  ear,  the  epithelium  of  the  mouth,  salivary  glands,  buccal 
portion  of  the  hj^pophysis  cerebri ;  the  epithelium  of  the  anus  and  male  urethra, 
with  the  exception  of  the  prostatic  portion;  the  central,  peripheral,  and  sympa- 
thetic nervous  systems;  the  retina;  neuroglia. 

II.  Hypoblastic  Structures. 

The  notochord;  the  epithelium  of  the  digestive  tract  and  associated  organs, 
oesophagus,  stomach,  intestines,  liver,  pancreas;  the  specific  cells  of  the  tonsils, 
thymus,  and  thyroid  glands,  parathyroids,  pharynx,  and  Eustachian  tube;  the 
epithelium  of  the  respiratory  tract,  larynx,  trachea,  and  lungs,  of  the  bladder, 
female  urethra,  and  the  prostatic  portion  of  the  male  urethra. 

III.  Mesoblastic  Structures. 

1.  Mesothelium. 

The  lining  cells  of  the  pleura^,  pericardium,  and  peritoneum;  the  specific 
cells  of  the  suprarenals,  kidneys,  testes,  ovaries  (Graafian  follicles);  the  epi- 
thelium and  glands  of  the  Fallopian  tubes,  uterus,  vagina,  vasa  deferentia,  vesic- 
ulse  seminales;  striated  muscles,  including  that  of  the  heart. 

2.  ]\Iesenchyma. 

Fibrous  connective  tissue,  cartilage,  bone,  reticulum  of  lymph  nodes,  bone 
marrow,  fat,  unstriated  muscle,  spleen,  the  endothelium  of  blood-vessels  and 
lymphatics,  blood  corpuscles,  the  endotheliiun  of  the  arachnoid,  synovial,  bur- 
sal, and  corneal  spaces;  nerve  sheaths. 

I.  Tumors  of  Epiblastic  Origix. 
Adenomata  and   cystadenomata  of  the   epidermal  glands  and  epithelimii  of 
the  tooth  papillEe;  epidermoids  (cholesteatoma)  and  inclusion  dermoids;  epi- 
thelioma; neuroma;  glioma. 

II.  TuiioRS  OF  Mesoblastic  Origin'. 

(a)  Mesothelial. — Adenoma  and   cystadenoma;  carcinoma;  rhabdomyoma; 

hypernephroma. 

(b)  Mesenchymatous. — Fibroma,  myxoma,  lipoma,  chondroma,  osteoma,  leio- 

myoma, angioma,  myeloma,  endothelioma  (perithelioma)  of  blood- 
vessels and  lymphatics;  sarcomata  of  all  kinds. 

III.  Tumors  of  Hypoblastic  Origin. 
Papilloma,  adenoma,  chordoma  (?),  carcinoma. 


300 


AMERICAN  PRACTICE  OF  SURGERY. 


The  accompanying  figure  (Fig.  84),  taken  from  Adami's  paper  above  referred 
to,  illustrates  in  a  graphic  way  the  differentiation  of  the  various  embryonal  tis- 
sues, at  the  same  time  indicating  their  function  and  relative  position. 

We  pass  on  now  to  the  consideration  of  the  special  varieties  of  tumors.  In- 
asmuch as  this  is  a  work  for  practical  surgeons,  I  have  not  ventured  to  adopt 
Adami's  classification,  though  I  believe  it  to  be  the  most  scientific  that  has  hith- 
erto been  devised.     It  involves,  however,  the  use  of  a  new  terminology,  and 


Fig.  84. — Scheme  of  Tissue  Relationships.      (Adami.) 
Lepidic  tissues  :  1,  Epiblast  (ectoderm  and  glands) :  2,  hypoblast  (entoderm  and  glands) ;    2',  noto- 

chord   (hypoblast);    3,    mesothelium   (hning    body-cavity),     with    derived    glands;     4,  endothelium 

(hning  vessels). 

Hylic  tissues:  5,  Epiblastic    (forming  nervous  tissues)  ;    6,  mesothelial   (forming  striated  muscles) ; 

7,  mesenchyme;   8,  pleuro-peritoneal  cavity;    9,   lumen  of  alimentary  canal. 

until  this  becomes  generally  understood  any  other  course  would  be  liable  to 
create  confusion.  Nevertheless,  in  view  of  the  importance  of  the  subject,  I  have 
introduced  as  alternative  designations  the  terms  employed  in  this  latest  attempt 
at  the  classification  of  new  growths  on  embryological  principles.  By  a  refer- 
ence to  the  schemata  given  above,  the  subject  will  be  made  sufficiently  plain. 


TUMORS  AND  TUMOR  FORMATION. 


301 


I.  TUMORS   OF  NON-EPITHELIAL   TYPE. 

These  may  be  benign  or  malignant.  For  the  most  part  they  are  mesoblastic 
and  mesenchymatous,  though  notable  exceptions  occur.  Histologically,  they 
manifest  this  important  peculiarity,  namely,  that  the  component  cells  are  em- 
bedded in  an  intercellular  matrix,  and  vessels  penetrate  between  many  of  the  cells. 
In  general  it  may  be  said  that  they  consist  of  connective  tissue  or  its  homologues. 

The  following  tumors  come  under  this  category : 

'  Fibroma. 

Myoma. 

Lipoma. 

Chondroma.  ^ 

Osteoma. 
Benign.  <j  Leiomyoma. 

Rhabdomyoma. 

jAiigioma. 

Glioma. 

Neuroma. 

Papilloma. 

Sarcoma. 

Endothelioma  (perithelioma) . 
Malignant.  ^  (a)  Of  blood-vessels  and 

I  lymphatics. 

1^  (b)  Of  serous  membranes. 


Typical  mesohylomata. 


f  Partly  hylic  and  partly  lepidic. 

y  Typical  epihylomata. 

!  Typical  epilepidoma. 
f  Atypical  mesohyloma. 

r  Atypical  mesolepidoma. 
j-  Endothelial  lepidoma. 


Fibromata. 

A  fibroma'  is  a  tumor  composed  in  the  main  of  fibrous  connective  tissue.  It 
contains,  however,  more  or  less  numerous  blood-vessels  and,  under  certain  cir- 
cumstances, nerves  or  other  structures. 

Fibromata  may  arise  from  any  tissue  or  organ,  provided  that  it  contain  con- 
nective tissue.  We  find  them,  therefore,  in  the  skin,  fascia,  the  sheaths  of  nerves, 
periosteum,  tendons,  the  mamma,  and  uterus,  less  often  in  the  ovary,  bladder, 
and  intestinal  tract.     They  are  among  the  commonest  of  tumors. 

In  general  terms  it  may  be  said  that. they  consist  of  nucleated  fibrous  cells, 
of  adult  or  nearly  adult  type,  held  together  by  a  fibrillar  matrix.  Several  sub- 
varieties  can  be  recognized,  according  to  certain  minor  differences  in  their 
structure. 

Being  benign  they  do  not,  of  course,  form  metastases,  but  not  infrequently 
enormous  numbers  of  separate  tumors  may  be  found  scattered  over  the  body. 
This  is  particularly  the  case  with  fibromata  of  the  skin  and  nerve  sheaths. 

To  macroscopic  appearance,  fibromata  may  assume  the  form  of  warty,  nodu- 
lar, papillomatous,  sessile,  or  diffuse  growths.  On  section,  the  denser  forms  are 
hard,  grating  under  the  knife,  white,  and  glistening,  with  a  fibrillated  structure 


302  AMERICAN  PRACTICE  OF  SURGERY. 

suggesting  the  appearance  of  watered  ribbon.  Tlie  softer  varieties  are  more 
homogeneous,  sometimes  semitranslucent,  and  the  fibrillated  structure  is  not  so 
evident.  The  larger  ones  are  not  invariably  uniform  in  texture,  but  may  con- 
tain harder  or  softer  areas,  patches  of  oedema  or  gelatinous  transformation,  or 
of  calcareous  infiltration  (fibroma  petrificum). 

Microscopically,  the  harder  forms  (fibroma  durum)  consist  of  a  dense  felt- 
work  of  coarse  interlacing  fibrils,  among  which  can  be  seen  somewhat  scanty, 
elongated,  spindle-shaped  nuclei.  Should  the  tumor  have  been  oedematous, 
the  fibrils  are  more  or  less  dissociated  and  the  cells  to  some  extent  hydropic. 
The  softer  forms  (fibroma  molle)  are  much  more  cellular;  the  nuclei  are  ^ore 
abundant,  plumper,  and  the  fibrils  are  more  delicate  and  aggregated  into  smaller 
bundles  (Fig.  85).     The  fibrils  are  never  arranged  in  regular  parallel  rows  or 


Fig.  85. — Soft  Fibroma.      Winckel  No.  6,  without  ocular.      (From  the  author's  collection.) 

layers,  but  interlace  freely,  and  the  various  bundles  may  lie  in  planes  that  inter- 
sect one  another'  at  various  angles.  Not  infrequently,  too,  the  fibres  are  clus- 
tered in  whorls,  generally  about  some  blood-vessel,  duct,  or  gland  tubule. 

Inasmuch  as  fibromata  are  composed  of  proliferating  fibrous  tissue,  we  would 
naturally  expect  to  find,  and  in  fact  this  is  not  uncommonly  the  case,  that  in 
certain  parts  there  are  cells  which  are  not  quite  so  mature  as  those  forming  the 
great  bulk  of  the  tumor,  roimd  or  stellate  cells,  and  cells  much  shorter  and 
plmiiper  than  the  ordinary  attenuated  fibrous  spindles.  This  peculiarity,  when  at 
all  marked,  often  indicates  a  transition  to  a  more  cellular  (sarcomatous)  condi- 
tion. The  transformation  of  the  young  tiurior  cells  into  the  adult  type  seems  to 
take  place  after  the  same  fashion  as  the  normal  proliferation  of  fibrous  tissue. 
Fibromata  are  not  always  pure,  but  maybe  associated  with  the  formation  of  adi- 


TUMORS  AND  TUMOR  FORMATION.  303 

pose  tissue  (fibroma  lipomatodes) ,  or  may  exhibit  in  parts  a  metaplasia  into  car- 
tilage or  bone  (fibroma  ossificum). 

The  vascularity  of  fibromata  varies  greatly.  The  blood-vessels  may  be 
scant}',  large,  and  numerous  (fibroma  teleangiectaticiim) ,  or  dilated  into  sinuses 
(fibroma  cavernosum) .  Similarly,  the  lymph  channels  may  be  abundant  (fibroma 
lymphangiectaticimi). 

Retrogressive  changes  are  not  common.  The  most  frequent  is  infiltration 
with  lime  salts.  Occasionally,  we  find  fatty  degeneration,  liquefaction-necro- 
sis, or  ulceration. 

There  are  certain  forms  of  fibromata  that  desei've  more  than  a  passing  men- 
tion. 

Pedunculated  fibromata  are  of  somewhat  frequent  occurrence.  They  may  be 
found  in  almost  any  part  of  the  skin,  but  generally  arise  from  the  external 
(female)  genitalia,  the  buttocks,  thighs,  or  shoulders.  "\^Tien  of  any  size,  they 
are  attached  to  the  part  by  a  narrow  pedicle,  and  in  time,  owing  to  impaired 
nutrition,  may  undergo  necrosis. 

The  so-called  "fibroid"  of  the  uterus  is  almost  invariably  a  mixed  tumor, 
consisting  of  a  variable  proportion  of  fibrous  tissue  and  unstriped  muscle  (myo- 
fibroma). Wlien  approximating  to  the  myomatous  type,  the  tumor  is  soft,  vas- 
cular, and  presents  a  reddish,  flesh-like  appearance.  AVlien  more  fibrous,  the 
growth  is  harder  and  much  paler  in  color.  Many  cases  can  hardly,  if  at  all,  be 
distinguished  by  their  gross  appearance  from  simple  fibromata. 

Uterine  fibroids  are  usually  multiple  and  vary  greatly  in  size.  They  may  be 
all  but  invisible  or  attain  the  size  of  a  man's  head  or  an  even  larger  object.  The 
largest  fibromata  that  we  meet  with  are  those  of  the  uterus.  The  larger  ones 
are  hard,  rounded,  and  nodular,  and  on  section  present  the  grayish-white,  glis- 
tening, fibrillated  appearance  of  the  hard  fibromata.  Often  nodules  or  whorls 
of  fibres  can  be  made  out.  A  blood-vessel  can  sometimes  be  detected  in  the 
centre  of  the  smaller  nodules.  Occasionally,  the  vessels  are  numerous,  dilated, 
or  sinus-like  (teleangiectatic  and  cavernous  myo-fibromata) . 

Microscopically,  both  muscular  and  fibrous  elements  can  be  detected  in  vary- 
ing proportions  (Fig.  93).  The  connective  tissue  tends  to  be  aggregated  about 
the  blood-vessels.  In  many  cases  the  tumor  consists  of  little  else  but  inter- 
lacing fibrils  of  fibrous  tissue,  forming  nodules,  strands,  and  whorls. 

In  order  of  frequency,  myo-fibromata  arise  from  the  posterior  wall  of  the 
corpus  uteri;  next,  from  the  anterior  wall;  and  lastly,  from  the  fmidus. 

According  to  the  site,  it  is  usual  to  recognize  four  types:  (1)  the  intramural 
or  interstitial,  (2)  the  s^ibserous,  (3)  the  submucous,  and  (4)  the  intraligamentous. 

The  subserous  myo-fibromata,  when  pedunculated,  ma}'  give  rise  to  grave 
symptoms.  Owing  to  interference  with  the  circulation  they  may  become  in- 
flamed, infarcted,  necrotic,  or  gangrenous.  By  their  size  fibromata  may  lead 
to  compression  of  the  uterus  and  other  important  structures. 


304  AMERICAN  PRACTICE  OF  SURGERY. 

The  etiology  of  uterine  fibroids  is  still  obscure.  They  do  not  occur  before  the 
age  of  puberty  and  are  most  common  in  elderly  women.  The  condition  is  said 
to  be  more  frequent  in  the  black  races. 

Fibroma  of  the  breast  is  perhaps  the  commonest  form  of  new  growth  found  in 
that  organ.  It  is  hardly  ever  met  with  in  the  male  sex.  It  generally  occurs  dur- 
ing the  period  of  active  sexual  life,  but  exceptionally  may  be  foimd  at  puberty  or 
after  the  menopause.  Some  cases  arise  without  obvious  cause,  but  many  are 
traceable  to  some  previous  diseased  condition  of  the  mamma,  such  as  mastitis  or 
abscess.  According  to  Thoma,  the  condition  is  hereditary  in  the  female  mem- 
bers of  some  families. 

Fibroma  of  the  mamma  occurs  under  two  main  forms :  as  ill-defined  strands 
of  connective  tissue  intersecting  the  organ  {fibroma  diffusum),  and  as  a  romided 
nodular  mass  {fibroma  tuberosuvi).  Nodular  fibromata  are  usually  multiple,  and 
one  or  more  of  them  may  greatly  exceed  the  others  in  size.  It  is  important  for 
the  surgeon  to  bear  in  mind  this  tendency  to  multiplicity,  as  it  has  an  important 
bearing  on  prognosis.  The  existence  of  other  minute  fibromata  and  the  ten- 
dency to  a  diffuse  fibromatosis  of  the  supporting  stroma  of  the  breast  explain  the 
subsequent  appearance  of  fibrous  tumors  after  the  operative  removal  of  the  more 
obtrusive  growth  (pseudo-recurrence). 

As  in  the  case  of  other  tumors  of  this  class,  manmiary  fibromata  are  rarely 
pure.  Proliferating  glandular  elements  are  almost  invariably  present  to  a  greater 
or  less  extent.  When  this  feature  is  marked  the  tumor  can  properly  be  termed  an 
adeno-fibroma.  Occasionally,  these  glandular  structures  are  dilated  into  cysts — 
cystadeno-fibroma — into  which  fibrous  processes  covered  with  epithelium  may 
project — papuliferous  cystadeno-fibroma. 

Microscopically,  the  nodular  fibromata  of  the  breast  are  composed  of  dense 
fibrous  tissue  in  which  are  to  be  found  more  or  less  abundantly  developed  gland- 
ular ducts  and  acini.  In  one  form  the  fibrous  tissue  is  laid  clown  in  dense  rings 
about  the  glandular  structures  {pericanalicular  fibroma) ;  in  other  cases  growth 
seems  to  be  so  excessive  that  papillomatous  outgrowths  force  their  way  into  the 
gland  spaces,  which  they  dilate  and  eventually  fill  up.  These  processes  are  cov- 
ered with  glandular  epithelium  {intracanalicular  fibroma). 

Nodular  fibromata  are  usually  situated  in  the  upper  half  of  the  breast  near  the 
periphery.  They  form  firm,  well-defined,  rounded  or  oval  masses,  lying  a  short 
distance  below  the  skin  or  in  the  depth  of  the  breast.  On  palpation  they  are 
tense,  so  that  it  may  be  difficult  to  determine  whether  they  are  cystic  or  not  with- 
out tapping,  but  may  be  definitely  fluctuating  in  parts.  They  are  often  irregu- 
larly nodular.  The  overlying  skin  is  not  attached  to  the  growth,  nor  are  the 
regional  lymph  nodes  enlarged.  In  the  intracanalicular  variety  there  may  be  a 
serous  discharge  from  the  nipple.  A  capsule  is  usuall}'  formed  so  that  the  growth 
is  freely  movable.  The  rate  of  growth  is  slow  and  the  tumor  rarely  attains  a 
large  size.     The  cystic  form,  which  is  apt  to  be  found  in  the  older  patients,  grows 


TUMORS  AND  TUMOR  FORMATION.  305 

somewhat  more  rapidlj'  than  the  other.  Fibromata  of  the  breast  usually  come 
into  evidence  for  the  first  time  at  the  puerperium  or  durmg  menstruation,  owing 
to  the  discomfort  that  they  occasion  at  such  times. 

The  peripheral  nerves  are  not  infrequently  the  site  of  multiple  primary  fibro- 
mata, which  arise  from  the  endoneurium.  The  tumors  appear  as  spindle-shaped 
thickenings  of  the  nerve  bundles  and  may  be  so  extensive  that  the  nerve  trunk 
undergoes  a  difi'use  or  irregular  nodular  thickening.  Microscopically,  these  fibro- 
mata are  of  the  soft  type.  In  the  case  of  the  smaller  spindles,  the  nerve  fibres  can 
easily  be  traced  passing  through  the  tumor,  but  in  the  larger  ones  they  can  be  de- 
tected only  at  the  points  of  entrance  and  exit  of  the  nerves.  As  the  physiological 
function  is  only  slightly,  if  at  all,  impaired,  it  is  probable  that  the  axis  cylinders 
are  not  destroyed.  A  new  formation  of  nerve  fibres,  such  as  has  been  claimed  by 
Klebs  and  others,  cannot  be  said  to  be  as  yet  substantiated,  so  that  the  name 
neitro- fibroma,  sometimes  applied  to  these  tumors,  is  incorrect. 

In  one  type  of  the  affection  the  nerve  trunks  are  the  seat  of  diffuse  fibrous 
thickening,  so  that  large,  subcutaneous  tumors,  composed  of  thick,  wormlike 
cords,  closely  intertwined,  are  formed  (plexiform  fibroma;  Rankenneurom) . 

The  multiple  soft  fibromata  found  in  the  skin,  constituting  the  affection 
known  as  moUusnmi  fibrosiim,  haA^e  been  sho\\Ti  by  Von  Recklinghausen  to  be 
fibromata  formed  on  the  peripheral  portions  of  the  cutaneous  nerves. 

It  may,  perhaps,  be  mentioned  here  that  one  variety  of  elephantiasis  is  due  to 
a  diffuse  and  extensive  fibromatosis  of  the  subcutaneous  tissue  similar  in  nature 
to  the  forms  just  described. 

A  very  curious  and  somewhat  rare  form  of  fibroma  is  the  so-called  keloid. 
Some  cases  arise  without  obvious  cause,  "idiopathic"  or  spontaneous  keloid; 
others  are  very  definitely  to  be  connected  with  some  previous  injury,  secondary, 
scar,  cicatricial,  or  spurious  keloid.  It  is  not  impossible,  however,  that  cases  of 
supposed  idiopathic  keloid  ought  to  be  attributed  to  some  previous  injury  which 
has  left  no  noticeable  trace,  or  has  been  so  slight  as  to  have  been  forgotten.  Cer- 
tain families  and  certain  races,  particularly  the  negro,  are  believed  to  be  specially 
predisposed  to  this  form  of  new  growth. 

Scar  keloid  often  follows  operations,  burns,  and  slight  cutaneous  injuries.  It 
has  been  known  to  occur  after  blistering,  in  the  scars  of  leech  bites,  after  piercing 
for  earrings,  after  shaving,  and  in  the  scars  left  by  various  eruptive  diseases. 

Keloid  may  be  met  with  in  the  form  of  oval  nodules,  elongated  cylindrical 
growths,  or  as  cordlike  elevations,  bands,  ridges,  or  radiating  processes.  Ke- 
loid growths  are  usually  single,  but  may  be  multiple.  The  tumor  is  firm,  elastic, 
elevated  above  the  general  surface,  and  sharply  defined.  It  is  adherent  to  the 
skin,  and  the  cutis  covering  it  is  thin,  smooth,  and  of  a  whitish  or  pinkish  color. 

Histologically,  keloid  is  a  fibroma  originating  in  the  corium  and,  it  is  believed, 
from  the  fibrous  adventitia  of  the  vessels  of  the  corium.  The  older  portions  of 
the  growth  are  of  the  type  of  the  fibroma  durum,  but  in  the  younger  parts  the 
VOL.  I.— 20 


306  AMERICAN  PRACTICE  OF  SURGERY. 

tumor  is  more  cellular.     The  various  laj^ers  of  the  corium,  papillte  and  rete  pegs, 
remain  intact. 

Keloid  tends  to  progress  for  a  number  of  years,  when  it  may  become  station- 
ary.    It  rarely  involutes  spontaneously. 

Myxomata. 
Myxomata  are  tumors  of  mucoid  character.  Structurally,  they  are  composed 
of  cells  floating  in  a  homogeneous,  semifluid,  mucinous  matrix.  The  cells  are 
mononuclear,  bipolar  or  stellate,  and  provided  with  more  or  less  elongated  proto- 
plasmic processes  which  interlace  freely  (Fig.  86).  The  intercellular  substance 
varies  in  amount  in  different  tumors  and  in  different  parts  of  the  same  tumor. 


Fig.  86. — Myxoma.      Winckel  No.  6,  without  ocular.      (From  tlie  author's  collection.) 

When  abundant  it  gives  a  characteristic  gelatinous,  semifluid,  somewhat  trans- 
lucent appearance  to  the  growth.  Myxomata  are  grayish  or  pinkish-gray  in 
color,  owing  to  the  presence  of  blood-vessels  that  are  more  or  less  distinctly  vis- 
ible in  the  substance.  On  section,  a  jelh'-like  or  ropy  substance — mucin — 
exudes,  which  is  not  soluble  in  water  and  gives  a  whitish  precipitate  when 
treated  with  alcohol  or  dilute  acetic  acid. 

Myxomata  are  rarely  pure  in  type,  but  are  usually  combined  with  other  tis- 
sues of  a  homologous  nature,  such  as  fibrous  tissue  (fibro-myxoma),  fat  {myxoma 
lipomatodes;  lipo-myxoma),  or  cartilage  (chondro-myxoma) . 

Mucoid  tissue  is  closely  related  to  fibrous  tissue.  The  truth  of  this  is  evident 
when  we  remember  that  in  the  fcetus  the  fibrous  and  fatty  tissues  are  first  blocked 
out  in  mucoid  material.  Consequently,  myxomata  are  commonly  met  with  in  the 
same  regions  from  which  fibromata  and  lipomata  also  spring.  Further,  mucoid 
tissue  occurs  in  the  adult  body  only  in  the  vitreous  humor  of  the  eye,  from  which 


TUMORS  AND  TUMOR  FORMATION.  307 

structure  myxomata  never  develop.  Myxomata,  therefore,  always  exhibit  a 
certain  deviation  from  the  tissues  in  which  they,  are  found.  In  other  words,  they 
are  heterologous  within  narrow  limits.  The  embryonic  character  of  the  cells  also 
explains  the  well-known  instability  of  the  tumor,  which,  though  classed  among 
the  benign  growths,  has  a  tendency  to  take  on  malignant  action,  the  transforma- 
tion occurring  in  the  direction  of  sarcoma  (myxosarcoma).  True  myxomata  have 
to  be  distinguished  on  the  one  hand  from  tumors,  such  as  fibromata,  sarcomata, 
and  carcinomata,  that  have  undergone  secondary  mucinous  degeneration,  and,  on 
the  other,  from  growths  that,  owing  to  vascular  disturbances,  have  become  oedem- 
atous.     In  both  cases  the  resemblance  may  be  striking. 

Myxomata,  fibro-myxomata,  and  lipo-myxomata  may  originate  in  the  con- 
nective tissue  of  the  skin,  fascia,  periosteum,  mucous  membranes,  and  muscle 
sheaths,  in  the  subcutaneous  and  subserous  fat,  the  bone  marrow,  and,  occasion- 
ally, in  the  mamma,  salivary  glands,  and  testis. 

Myxomata  of  the  mucous  membranes  occur  singly  or  as  multiple  primary 
tumors.  The  ordinary  mucous  polyp  of  the  nose  is  a  good  example  of  these 
growths.  Similar  tumors  are  sometimes  found  in  the  larynx,  intestinal  tract, 
and  uterus.  They  approximate  in  structure  to  pure  myxomata  and  often  con- 
tain more  or  less  altered  portions  of  mucous  glands.  Some  of  the  cases  can  be 
traced  with  some  probability  to  the  irritation  caused  by  a  pre-existing  catarrh  of 
the  mucous  membrane  affected,  but  this  influence  cannot  always  be  effective. 

The  hydatidiform  mole  of  the  uterus  is  a  myxomatous  transformation  of  the 
chorionic  villi  {myxoma  chorii  racemosum). 

Myxo-sarcomata,  so  called,  are  due  either  to  a  cellular  transformation  of  a  sim- 
ple fibro-myxoma,  or  to  the  mucinous  degeneration  of  a  sarcoma.  They  behave 
as  sarcomata  and  form  metastases. 

LiPOMATA. 

Lipoinata  are  tumors  composed  in  the  main  of  adipose  tissue.  They  form  soft 
or  moderately  firm  growths,  well  defined,  nodular,  often  lobulated  (Fig.  87). 
They  vary  greatly  in  size.  Those  found  in  the  internal  viscera,  such  as  the  kid- 
ney, are  often  only  discovered  on  microscopical  examination,  but  those  met  with 
in  the  svibcutaneous  and  retroperitoneal  tissues  may  attain  a  notable  size.  The 
superficial  ones,  on  palpation,  are  soft  and  yielding.  On  section,  they  are  com- 
posed of  masses  of  fat  bounded  and  held  together  by  fibrous  septa. 

Microscopically,  the  fat  cells  bear  a  general  resemblance  to  those  of  the  subcu- 
taneous tissues,  but  are  larger  (Fig.  88).  Not  infrequently  there  is  a  considerable 
admixture  of  other  elements,  such  as  fibrous  tissue  (fibro-lipo7na) ,  mucoid  tissue 
{myxo-lipoma) .    The  blood-vessels  vary  greatly  in  numbers  and  size. 

The  lipoma  is  ordinarily  a  benign  ttimor.  The  sarcomatous  transformation 
which  is  occasionally  seen  can  only  occur  after  the  metaplasia  of  the  cells  of  the 
tumor  into  fibrous  or  myxomatous  tissue. 


308  tSlMERICAN  PRACTICE  OF  SURGERY. 

Lipomata  may  occur  in  the  new-born,  as,  for  example,  the  tumors  that  de- 
velop at  or  near  the  fissure  in  cases  of  spina  bifida,  but  are  much  more  common  in 
later  life  They  are  found  most  frequently  starting  from  the  subcutaneous  tis- 
sue of  the  back,  buttock,  thigh,  abdominal  wall,  throat,  and  axilla,  less  often  from 
the  intermiiscular  connective  tissue,  the  subserous  fat  of  the  peritoneal  cavity, 
the  kidneys,  mamma,  the  hands  and  fingers,  under  the  aponeurosis  of  the  frontal 
region,  and  in  the  meninges.  They  originate  usually  from  pre-existing  adipose 
tissue,  but  can  develop  from  fibrous  tissue  containing  no  fat,  as,  for  instance,  the 
submucosa  of  the  intestines.  Masses  of  newly  formed  fat  occasionally  form  in 
the  epicardium  and  around  the  kidneys,  especially  in  alcoholics  and.-those 
suffering  from  interstitial  nephritis,  and  are  sometimes  called  lipomata.     Before, 


Fig.  87. — Lipoma  from  the  Subcutaneous  Tissues  of  the  Gluteal  Region.     (Pathological  Museum  of 
McGill  University.) 

however,  we  can  be  sure  that  such  accumulations  of  fat  are  true  tumors  we 
must  be  certain  that  they  possess  independent  powers  of  proliferation.  The 
autonomous  nature  of  true  lipomata  is  proved  by  the  fact  that  when,  from 
any  cause,  the  general  fat  of  the  body  is  disappearing,  the  tumor  itself  remains 
unaffected. 

Lipomata  grow  slowly  and  produce  no  effects  save  those  of  pressure.  They 
are  sharply  bounded,  do  not  infiltrate,  and  never  form  metastases.  Like  the 
fibromata  they  are  not  infrequently  multiple,  and,  curiously  enough,  in  some  in- 
stances are  symmetrically  distributed.  When  of  large  size  they  are  liable  to  be 
the  seat  of  degenerative  processes,  calcification,  necrosis,  gangrene,  or  ulceration. 
The  ulcers  produced  are  often  very  foul,  owing  to  the  presence  of  fatty  acids. 
Unless  of  large  size,  lipomata  cause  little  trouble,  but  occasionally  sxirgical  inter- 


TUMORS  AND  TUMOR  FORMATION.  309 

ference  is  called  for  to  remove  tumors  that  are  situated  in  awkward  places  or  are 
troublesome  on  account  of  their  weight. 

Perhaps  the  form  of  most  interest  and  importance  is  the  retroperitoneal  li- 
poma, so  called.  This  is  a  somewhat  rare  form  of  lipoma,  but  occurs  sufficiently 
often  to  warrant  a  detailed  description.  It  is  met  with  usually  in  those  about 
middle  life  or  somewhat  later,  but  exceptionally  has  been  observed  shortly  after 
birth  (Lauwers).  The  female  sex  is  somewhat  more  often  affected  than  the 
male.  The  growth  begins  in  the  radix  mesenterii  or  perirenal  fat,  less  often  in 
the  subserous  fat  lower  down.  The  rate  of  growth  is  slow,  two  or  three  years 
usually  elapsing  before  death  takes  place.  Enlargement  of  the  abdomen,  often 
asymmetrical,  gradually  supervenes,  but  for  a  long  time  produces  no  impleas- 


FiG.  88. — Lipoma.      Winckel  No.  3,  witliout  ocular.      (From  the  autlior's  collection.) 

ant  subjective  symptoms.  Some  few  subjects  have  suffered  from  vomiting,  colic, 
flatulency,  or  other  digestive  disturbances.  A^Hien,  however,  the  growth  becomes 
large  it  leads  to  pressure  symptoms,  intestinal  obstruction,  dyspnoea,  and  oedema 
of  the  lower  extremities.  In  the  later  stages,  weakness  and  emaciation  are 
marked  features.  On  examination,  the  abdomen  is  often  enormously  distended 
and  gives  the  sensation  of  fluctuation.  The  percussion  note  is  dull,  but  not  in- 
frequently a  band  of  tympany  can  be  traced  across  the  front  of  the  abdomen,  due 
to  the  fact  that  the  colon  is  pushed  forward  and  lies  over  the  tumor.  Fluctuation 
is  a  characteristic  feature  and  simulates  so  closely  an  accumulation  of  fluid  that 
the  erroneous  diagnosis  of  ascites,  ovarian  cyst,  and  echinococcus  cyst  has  been 
made.  The  insertion  of  a  trocar  readily  demonstrates,  however,  the  nature  of  the 
growth.  A  dry  tap  under  these  circumstances  should  always  suggest  the  proba- 
bility of  a  retroperitoneal  lipoma  being  present. 


310  AMERICAN  PRACTICE  OF  SURGERY. 

The  size  which  these  tumors  may  attain  is  extraordinary.  Adami  (Mon- 
treal Medical  Journal,  January  and  February,  1897)  has  reported  one  approxi- 
mating forty-five  pounds  in  weight,  and  Waldeyer  {Virch.  Arch.,  XXXII.,  1865, 
p.  543)  one  of  sixty-three  pounds. 

Histologically,  they  are  rarely,  if  ever,  pure  lipomata.  All  sorts  of  combi- 
nations of  fatty  tissue  with  its  homologues,  fibrous  tissue,  mucoid  tissue,  carti- 
lage, and  bone,  may  occur.  Perhaps  the  majority  are  of  the  nature  of  myxolipo- 
mata  (lipoma  myxomatodes) .     Deposits  of  calcareous  salts  may  occur. 

Such  lipomata  produce  their  effects  by  reason  of  their  size  and  are  not  ordi- 
narily malignant.  In  a  case  of  Waldeyer's  secondary  growths  developed  in 
other  parts.  This  occurrence  is  readily  explained  when  we  find  that  the  larger 
lipomata  of  this  type  almost  invariably  present  sarcomatous  transformation  in 
some  part  or  other,  a  change  which  will  usually  be  revealed  on  careful  exam- 
nation. 

The  causes  at  work  in  the  production  of  lipomata  are  somewhat  obscure. 
Traumatism  seems  to  be  of  some  importance.  Thus,  tumors  of  this  nature  have 
been  known  to  develop  in  an  old  scar.  The  rather  frequent  occurrence  of  lipo- 
mata about  the  shoulders  has  suggested  that  the  pressure  of  clothing  or  suspend- 
ers may  have  something  to  do  with  it.  The  facts  that  lipomata  are  sometimes 
found  in  infants,  especially  those  affected  by  spina  bifida,  and  that  adipose  tissue 
is  an  important  constituent  of  some  teratomata,  make  it  probable  that  a  congen- 
ital vice  of  development  is  at  work  in  some  cases.  This  view  is  supported  to  some 
extent  by  the  fact  that  certain  lipomata  of  the  kidney  are  traceable  to  aberrant 
suprarenal  "rests."  The  symmetrical  distribution  of  the  growths  in  some  in- 
stances has  been  explained  on  the  basis  of  a  neurotrophic  disturbance. 

In  not  a  few  cases,  however,  none  of  the  influences  mentioned  can  be  traced. 

Choxdromata. 

Tumors  consisting  in  the  main  of  cartilage  are  called  chondromata.  They 
vary  considerably  in  size.  The  smaller  ones  are  approximately  spherical,  while 
the  larger  are  apt  to  be  irregular,  nodular,  or  lobulated.  The  major  part  of 
the  growth  is  composed  of  hyaline,  fibro-,  or  elastic  cartilage,  which  is  enclosed  in 
a  fibrous  capsule  carrying  the  nutrient  vessels.  In  the  larger  cartilaginous  tumors 
there  are,  in  addition,  numerous  vascular  fibrous  trabeculse  dividing  the  carti- 
lage into  a  number  of  islands. 

Chondromata  are  of  almost  stony  hardness,  unless  they  are  degenerated,  and 
on  section  have  a  whitish,  somewhat  translucent  appearance.  The  larger  ones 
not  infrequently  show  areas  of  softening  or  of  calcification,  and  may  contain 
cystic  cavities  filled  with  a  gelatinous  material. 

Cartilaginous  tumors  commonly  develop  in  situations  where  cartilage  is  nor- 
mally present,  but  occasionally  arise  in  structures  that  are  devoid  of  cartilage, 
such  as  the  parotid  gland,  the  testis,  mamma,  submaxillary  gland,  and  skin. 


TUMORS  AND  TUMOR  FORMATION. 


311 


They  originate  in  the  proHferation  of  normal  pre-existing  cartilage  cells  (ec- 
chondromata) ,  or  they  may  arise  from  other  forms  of  connective  tissue,  espe- 
ciall}^  fibrous  tissue  {enchondroynata) . 

Histological  examination  reveals  a  certain  amount  of  variation  in  structure. 
Not  only  may  these  differences  exist  between  tumors,  but  between  different  parts 
of  the  same  tumor.  The  cartilage  is  usually  of  the  hyaline  variety,  less  often 
elastic  or  fibrous.  Even  in  hyaline  chondroniata  there  may  be  here  and  there 
areas  of  a  more  fibrous  character,  and  at  the  periphery  the  cartilaginous  structure 
merges  gradually  into  the  fibrous  investing  membrane.  The  cartilage  cells  proper 
vary  considerably  in  numbers,  size,  shape,  and  arrangement.  They  may  be  large 
or  small,  rounded,  spindle-shaped,  or  stellate.  In  some  cases  they  are  abundant, 
in  other  cases  scanty.     It  is  not  uncommon  to  find  evidences  of  retrogression  such 


Fig.  89. — Chondroma  from   Mamma  of  Bitch.     At   one  point  the  specimen  shows  a  calcareous 
deposit.      Winckel  No.  3,  without  ocular.      (From  the  author's  collection.) 

as  fatty  degeneration,  mucinous  degeneration,  liquefaction,  and  calcification.  In 
many  instances  we  can  recognize  in  parts  myxomatous  tissue  (myxo-chondmna) 
or  true  bone  (osteo-chondroma)  (Fig.  89). 

Ecchondromata  take  the  form  of  rounded  or  polypoid  outgrowths  and  are 
usually  primarily  multiple.  They  arise  from  the  cartilage  of  the  ribs,  trachea, 
larynx,  intervertebral  discs,  or  elsewhere,  and  not  infrequently  present  eviden- 
ces of  myxomatous  change,  petrifaction,  or  ossification.  The  ecchondrosis  physa- 
lifera  of  Virchow,  otherwise  called  chordoma,  is  a  curious  tumor  about  the  size  of  a 
cherry,  arising  from  the  clivus  Blumenbachii  or  the  spheno-occipital  synchon- 
drosis. As  it  grows  it  pushes  the  dura  before  it,  and,  when  the  symphysis  is  ossi- 
fied, appears  as  a  rounded  mass  attached  by  a  short  pedicle  to  a  small  conical 


312  AMERICAN  PRACTICE  OF  SURGERY. 

elevation  on  the  surface  of  the  bone.  It  is  firmi}'  adherent  to  the  dura.  It  used 
to  be  thought  that  this  remarkable  growth  originated  in  the  remains  of  the  embry- 
onic notochord,  but  this  is  now  known  to  be  incorrect. 

Enchondromata  nsualh'  occiu*  in  bones  and  originate  mthe  periosteum  or  bone 
marrow,  but  never  from  the  articular  cartilages.  In  regard  to  situation  they  par- 
ticularh^  affect,  among  the  long  bones,  the  phalanges  of  the  hands  and  feet  and 
the  femur.  The  enchondromata  of  the  phalanges  are  usually  multiple  primary 
growths,  starting  from  different  bones,  and  may  appear  durmg  the  early  years  of 
life.  They  may  attain  the  size  of  the  fist  (Fig.  90).  .\nrong  other  parts  of  the 
skeleton  the  flat  bones  of  the  pelvis  and  shoulder  girdle,  and  the  maxillae,  are  often 


^^■^^B 

I 

m 

^/A 

^^■H 

^^^^^^H 

1 

psy 

^."^  ^^B 

^[^^^^E"" 

p 

-* 

' 

\  1 

i 

~^^*- 

1 

^^^^^^^ 

b 

:^ 

-'*!^^^^l 

Fig.  90. — Chondroma  of  the  Phalanges  ;  section  made  in   an  axial  direction.      (^Pathological  Museum 
of  McGill  University.) 

involved.     The  enchondromata  of  the  femur,  pelvis,  and  shoulder  girdle  may 
grow  to  an  enormous  size. 

Perhaps  the  most  interesting  of  the  enchondromata  are  those  forms  that  arise 
in  the  parotid  or  testis,  and  m  other  structures  that  normally  do  not  contain  car- 
tilage. As  a  rule  they  are  of  a  mixed  type.  The  mixed  tumor  of  the  parotid  and 
submaxillary  glands  is  composed  of  fibro-cartilage,  containmg  more  or  less  numer- 
ous irregular  epithelial  elements,  remains  of  the  original  glandular  acini  which 
have  become  enclosed  in  the  tumor.  Connective  tissue  and  myxomatous  tissue 
are  also  commonly  present,  and  there  may  be  a  cellular  variation  in  the  direction 
of  sarcomatous  or  carcinomatous  metamorphosis.  The  mixed  ttmiors  of  the  testis 
are  similar  except  that  they  are  as  a  rule  composed  of  hyaline  cartilage.  These 
mixed  growths  are  malignant  and  form  metastases  through  the  blood-  or  lymph- 


TUMORS  AND  TUMOR  FORMATION.  313 

channels,  metastases  which  are  sarcomatous  or  carcinomatous  in  character.  It 
should  not  be  forgotten,  also,  that  apparently  siniple  enchondromatamay,  on  occa- 
sion, produce  metastases.  For  this  to  occur  it  would  seem  that  a  preliminary  mucm- 
ous  degeneration  of  the  tissue  must  take  place.  Multiple  small,  rounded,  local, 
metastatic  growths,  varying  in  size  from  that  of  a  bean  to  that  of  a  walnut,  are 
sometimes  to  be  found  among  the  muscles  in  the  neighborhood  of  large  enchon- 
dromata  of  the  shoulder  girdle,  pelvis,  and  femur,  which  have  become  softened  at 
the  centre.  Metastases  are  also  occasionally  found  in  the  internal  viscera,  notably 
the  lungs,  and  lymph  nodes.  To  account  for  these,  an  ingrowth  of  the  cartilage 
cells  into  the  large  veins  has  been  observed  (Virchow).  This  power  of  forming 
metastases  is  a  somewhat  variable  one.  Short  of  forming  regular  secondary  nod- 
ules in  distant  parts,  a  somewhat  rare  event,  we  may  have  local  metastasis,  or 
simply  a  tendency  on  the  part  of  the  tumor  to  send  in  processes  into  the  inter- 
stices of  the  tissues  in  the  immediate  neighborhood.  At  all  events,  the  pecul- 
iarity is  sufficiently  well  marked  to  stamp  the  enchondromata  as  relatively  the 
most  malignant  of  the  organoid  tumors. 

With  regard  to  the  etiology  of  chondromata  we  are  on  somewhat  firmer  ground 
than  we  are  in  regard  to  some  other  tumors.  Cartilaginous  new  formations  may 
arise  from  pre-existing  cartilage  cells  which  have  taken  on  excessive  action,  though 
we  can  no  more  explain  the  essential  nature  of  this  increased  activity  of  growth 
than  we  can  in  the  case  of  tumors  generally.  In  the  case  of  the  enchondroma 
of  bone,  Virchow's  explanation  is  commonly  accepted,  namely,  that  during  the 
post-embryonic  development  of  bone,  islets  of  cartilage  become  displaced,  owing 
probably  to  rachitic  processes,  and  subsequently  proliferate.'  The  heterologous 
tumors  of  the  parotid,  salivary  glands,  testis,  and  skin  are  best  to  be  explained 
as  originating  in  misplaced  embryonic  "rests."  Defective  closure  of  the  bran- 
chial clefts  is  an  important  factor  in  the  case  of  the  enchondromata  of  the  sali- 
vary glands  and  the  skin  of  the  neck. 

Apart  from  the  rather  rare  event  of  the  formation  of  metastases,  chondromata 
produce  their  effects  largely  by  pressure  and  by  their  size.  Superficial  chondro- 
mata may  soften  in  the  centre  and  discharge  the  liquefied  material  through  the 
skin,  so  that  a  necrotic  cavity  is  produced  which  subsequently  suppurates.  A 
chronic  ulcer  is  thus  formed  which  shows  no  tendency  to  heal  and  subjects 
the  patient  to  the  danger  of  general  septic  infection. 

OSTEOMATA. 

Tumors  composed  of  osseous  tissue  are  called  osteomata.  Two  main  varieties 
are  recognized,  the  osteoma  eburneum,  formed  of  compact  bone,  and  the  osteoma 
spongiosum  or  medullary  osteoma,  corresponding  in  structure  to  the  spongy  por- 
tion of  normal  bone.  Besides  these,  there  are  certain  new  formations  of  bone, 
which  are  more  or  less  doubtfully  to  be  included  in  the  category  of  true  tumors,  and 
to  which  special  names  are  given.     Circumscribed  outgrowths  on  the  external  sur- 


314 


AMERICAN  PRACTICE  OF  SURGERY. 


face  of  bones  are  termed  osteophytes,  or,  if  tumor-like,  exostoses  (cortical  oste- 
omata).  Circumscribed  outgrowths  within  the  substance  of  bones  are  known  as 
enostoses  (central  osteomata).  Hyperostosis  is  a  diffuse  and  generalized  increase 
in  the  bulk  of  a  bone. 

Osteomata  are  single  or  multiple,  and  arise  usually  from  bones  and  teeth,  peri- 
osteum, and  from  the  attacluiients  of  fasciae,  tendons,  and  ligaments  (Fig.  91). 
Fascial,  tendinous,  and  ligamentous  osteomata  may  be  firmly  miited  to  the  bone 
{co7itinuous  fascial,  tendinous,  anA.  ligamentous  osteomata),  or  be  separate  from  it 
and  often  movable  {discontinuous  osteomata).  Exceptionally,  osteomata  originate 
from  the  soft  tissues,  such  as  the  muscles,  dura,  choroid  and  sclerotic,  penis. 


Fig.  91. — Osteoma  in  the  Falx  Cerebri.     (Pathological  Museum  of  JIcGill  University.) 


Heteroplastic  osteomata  are  sometimes  met  with  in  the  parotid,  lungs,  brain,  dia- 
phragm, skin,  and  tongue. 

In  appearance  osteomata  nvdy  be  uniformly  smooth,  conical,  rounded,  or 
button-like,  or,  again,  irregular,  rough,  and  warty. 

The  hard  osteomata,  or  osteomata  eburnea,  are  of  dense  ivory-like  consist- 
ence, and  are  composed  of  thick,  compact  bone,  with  relatively  small  nutritive 
canals,  resembling  the  cortical  substance  of  the  long  bones. 

The  spongy  osteomata  are  similar  to  normal  spongy  bone,  and  are  made  up  of 
delicate  bony  trabeculse  enclosing  wide  marrow  spaces. 

Dental  osteomata  origmate  in  the  cement  of  the  tooth,  which  consists  of  true 
bony  tissue.  They  start  from  the  root  of  the  tooth,  where  thej^  form  masses  vary- 
ing in  size.  The  odontoma  is  composed  of  dentin  and  occurs  not  only  on  the  root, 
but  also  on  the  neck  and  crown  of  -the  tooth.  It  is  to  be  attributed  to  some  dis- 
turbance of  the  pulp  during  the  development  of  the  tooth. 


TUMORS  AND  TTOIOR  FORMATION.  315 

The  osteoid  tumors,  growths  closely  allied  to  the  osteomata,  and,  in  fact, 
forming  a  subvariety  of  them,  deserve  mention.  They  arise  from  the  periosteum, 
chiefly  from  that  of  the  larger  long  bones,  such  as  the  htmierus  and  femur.  They 
are  composed  of  osteoid  tissue,  which  differs  from  bony  tissue  only  in  the  fact  that 
it  is  devoid  of  calcareous  salts.  These  tumors  have  been  confused  with  the  carti- 
laginous growths,  and  have  been  termed  osteoid  chondromata,  but  are  distin- 
guished from  them  by  the  fact  that  they  contain  numerous  Haversian  canals  car- 
rying the  nutrient  vessels. 

The  hLstogenetic  development  of  osteomata  is  interesting.  In  some  cases  the 
formation  of  the  new  bony  tissue  takes  place  after  the  fashion  of  normal  bone, 
that  is  to  say,  through  the  agency  of  osteoblasts,  or  by  a  process  of  metaplasia. 
In  this  way  bony  tumors  can  arise  either  from  the  bone  marrow  or  from  the  peri- 
osteum. The  proliferating  cells  may  give  rise,  m  the  first  instance,  to  cartilage, 
which  subsequently  is  converted  into  bone  (cartilaginous  exostosis),  or  the  bone 
may  arise  directly  from  connective  tissue  (connective-tissue  exostosis).  The  hard 
osteomata  of  the  calvarium  are  probably  to  be  referred  to  excessive  local  subperi- 
osteal osteogenesis.  The  irregular,  flattened  plates  and  spicules  of  bone  or  oste- 
oid substance  which  are  foimd  in  the  dura  of  the  brain  and  cord  have  been  ex- 
plained on  the  basis  of  a  reversion  of  the  dura  to  its  more  primitive  osteogenetic 
function. 

The  multiple  osteomata  bear  certain  close  analogies  to  the  multiple  chondro- 
mata. Many  of  them  occur  during  the  active  period  of  growth,  and  are  con- 
nected with  the  articular  surfaces  of  bones,  suggesting  some  anomaly  of  devel- 
opment. A  hereditary  tendency  has  been  traced  in  some  cases  (Heymann, 
Nasse) ;  and  rickets,  as  in  the  case  of  the  chondromata,  may  play  an  important 
role.  Bessel-Hagen  and  Nasse  draw  attention  to  the  fact  that  persons  the  sub- 
jects of  multiple  osteomata  often  present  other  disturbances  of  development  in 
the  skeleton.  The  heteroplastic  osteomata,  such  as  those  found  in  the  parotid 
and  tongue,  are  to  be  attributed  to  misplaced  cells  or  embryonic  "rests."  Final- 
ly, osteomata  may  apparently  originate  in  the  proliferation  of  cellular  elements 
of  unknown  character. 

Besides  the  forms  above  mentioned,  there  are  a  number  of  others  that  can 
hardly  be  included  among  the  tumors,  inasmuch  as  they  are  not  autonomous  new 
formations.  Such  are  many  osteophytes,  hyperostoses,  and  exostoses,  certain  of 
the  discontinuous  osteomata,  the  bony  plates  that  sometimes  form  m  the  choroid 
and  sclerotic,  and  the  irregular  masses  of  bone  found  in  muscle.  In  many  cases 
irritation  of  some  kind,  or  inflammation,  appears  to  be  the  predisposing  cause, 
though  it  seems  likely  that  such  can  only  act  in  the  presence  of  some  inherited 
tendency  to  cell  proliferation.  Of  this  nature  are  the  so-called  "riders'  bone" 
and  "exercise  bone"  that  sometimes  develop  in  the  adductors  of  the  femora  and 
in  the  deltoid,  and,  possibly,  also  the  extensive  and  progressive  ossification  of  the 
connective  tissue  of  the  muscle  in  the  curious  disease  known  as  myositis  ossificans. 


316 


A]\'IERICAN  PRACTICE  OF  SURGERY. 


^Iyomata. 

Myomata  are  tumors  consisting  chiefly  of  muscle  fibres.  Two  varieties  can 
be  recognized,  those  composed  of  striated  muscle,  rhabdomyoma  (myoma  strio- 
cellulare),  and  those  formed  of  unstriped  muscle,  leiomyoma  (myoma  lavicel- 
lulare) . 

The  rhabdomyoma  (von  Zenker)  is  a  somewhat  rare  form,  the  peculiar  featm'e 
of  which  is  that  it  is  composed  of  more  or  less  embr3'onic  or  mrdifferentiated 
striated-muscle  cells.  The  cells  of  more  adult  t}'pe  occur  as  multmucleated 
ribbon-like  masses  of  protoplasm  of  varying  thickness,  presenting  well-marked 
transverse  striation  and  sometimes  also  longitudinal  fibrillation.  The  more  im- 
mature cells  are  in  various  stages  of  differentiation.     There  are  round  cells,  pos- 


FiG.  92. — Fibro-myoma  (''  Fibroid  ")  of   tlie  Uterus.      Tlie  darker  tissue  consists  or  unstriped  muscle  ; 
the  lighter,  of  fibrous  tissue.      Winokel  No.  3,  without  ocular.      (From  the  author's  collection.) 

sessmg  no  special  peculiarities,  that  are  scarcel}-,  if  at  all,  to  be  distinguished 
from  the  earliest  forms  of  connective-tissue  cells;  irregularly  rounded  or  oval 
cells,  presenting  radial  or  concentric  striations;  spindle  cells  having  long  process- 
es, with  or  without  a  faint  striation;  and  small  ribbon-like  masses  of  proto- 
plasm without  stria?.  The  bands  and  spindles  are  aggregated  into  bundles  and 
interlace  more  or  less  freel}'. 

To  gross  appearance,  there  is  nothing  specially  characteristic  of  the  rhabdo- 
myomata.  They  form  nodular  growths,  and,  if  on  a  free  surface,  may  have  a 
papillomatous  or  polypoid  arrangement. 

It  is  important  to  recognize  the  fact  that  the  rhabdomyoma  is  a  tumor  of  em- 
bryonic type.  Its  cells  always  fail  in  attainmg  perfect  maturity.  Conse- 
quently, we  ought  to  class  these  growths  along  with  the  myxomata  and  chondro- 


TUMORS  AND  TUilOR  FORMATION. 


317 


niata  as  tumors  of  unstable  character,  tending  to  be  malignant.  The  presence  in  \ 
rhabdomyomata  of  comparativelj-  imdifferentiated  romid  and  spindle  cells  has 
led  some  to  fall  into  the  error  of  regarding  these  as  immature  connective-tissue 
elements,  and  calling  such  growths  rhabdomyo-sarcomata.  It  is  more  natural  to 
suppose  that  the  cells  in  question  are  simply  striated-muscle  cells  in  an  embry- 
onic condition,  though  it  cannot  be  denied  that  a  sarcomatous  variation  of  the 
connective  tissue  of  rhabdomyomata  does  occasionally  take  place. 

Rhabdomyomata  ma}^  arise  in  structures  normally  containing  striated-muscle 
fibres,  but  are  usually  heterologous.  In  more  than  half  the  cases  the  growth  orig- 
inates in  the  kidney  or  kidney  pelvis ;  less  often  it  is  in  the  testicle  or  uterus ; 
rarely  it  has  been  foimd  in  the  vagina,  urinary  bladder,  the  volimtary  muscles, 
the  wall  of  the  heart,  subcutaneous  tissue,  mediastinum,  oesophagus,  stomach,  pa- 


Fig.  93. — Myoma  from  the  .A.rm.      Winckel  Xo.  3,  ■svithout  ocular.      (From  the  author's  collection.) 

rotid,  and  orbit.  Newly  formed  striated-muscle  fibres  may  also  be  recognized  in 
that  peculiar  congenital  condition  kno'mi  as  macroglossia. 

The  facts  that  the  majority  of  these  tumors  are  foimcl  in  situations  devoid 
normally  of  muscle,  where  the  various  infoldings  of  the  different  germ  layers  are 
very  complicated,  and  that  they  occur  frequently  at  birth  or  shortly  after,  sug- 
gest that  they  arise  from  misplaced  muscle  "rests"  derived  from  the  primitive 
myotomes.  In  certain  teratoid  tumors  striated  muscle  is  foimd  combined  with 
cartilage,  bone,  and  epithelial  elements. 

Much  more  common  are  the  tumors  composed  of  smooth-muscle  fibres.  They 
are  found  most  often  in  the  uterus  and  prostate,  occasionally  m  the  alimentary 
tract  and  m'inary  passages,  more  rarely  in  the  skin  and  subcutaneous  tissues. 
Structurally,  they  are  composed  of  smooth  muscle  fibres,  arranged  in  bundles 
which  intersect  one  another  in  different  directions,  embedded  in  more  or  less  vas- 


318 


AMERICAN  PRACTICE  OF  SURGERY. 


cular  connective  tissue.  According  to  the  predominance  of  one  or  other  of  these 
elements  we  may  recognize  a  myoma  fibrosum  or  fbromyoma,  a  myoma  teleangi- 
ectaticum  or  cavernosum,  or  a  pure  myoma,  myoma  molle.  Not  infrequently  the 
connective-tissue  elements  are  so  abundant  as  to  warrant  us  in  calling  the  tumor 
a  myo-fibro7na.  The  majority  of  the  uterine  myomata,  so-called,  are  of  this  type. 
In  fact,  in  America  at  least,  they  are  more  properly  classed  with  the  fibromata 
than  with  the  myomata.    (Fig.  92.) 

Myomata  and  fibro-myomata  form  irregular  or  warty-looking  tmnors,  which 
on  section  present  a  variable  appearance  according  to  their  nature.     The  fibrous 


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Fig.  94. — Myomatous  Enlargement  of  the  Prostate ,  obstruction  to  the  outflow  of  urine  caused  by 
the  overgrowth  of  the  so-called  middle  lobe;  consecutive  hypertrophy  of  the  wall  of  the  bladder. 
(Pathological  Museum  of  McGill  University. 


portion  is  of  fibrillated  texture,  firm,  and  of  a  shining  white  color;  the  muscular 
part  is  pinkish  or  bright  grayish-red. 

Histologically,  the  muscle  fibres  may  be  recognized  by  the  fact  that  they  are 
long  spindles  arranged  somewhat  regularly  into  bundles,  and  possess  elongated  rod- 
shaped  nuclei  (Fig.  93).  The  character  of  the  cells  can  usually  be  ascertained  on 
macerating  some  fresh  material  for  from  twenty  to  thirty  minutes  in  from  three 


TUMORS  AND  TUMOR  FORMATION.  319 

to  four  per  cent,  caustic-potash  solution  and  then  teasing  it  out  with  needles. 
Degenerative  changes,  fatty  degeneration,  softening,  cyst  formation,  and  calcifi- 
cation are  not  uncommon  events  in  leiomyomata.  Occasionally,  the  muscle  fibres 
may  atrophy,  thus  converting  the  tumor  into  a  simple  fibroma. 

Leiomyomata  are  benign  tumors  and  develop  during  adult  or  advanced  life. 
Very  exceptionally  leiomyomata  have  been  observed  during  the  first  few  years  of 
life. 

With  regard  to  their  mode  of  origin,  it  may  be  said  in  general  terms  that  they 
may  arise  wherever  there  is  unstriped  muscle.  In  the  case  of  uterine  myomata 
and  certain  myomata  of  the  skin,  the  muscle  bundles  can  often  be  made  out  to  be 
arranged  around  the  vessels,  the  ramifications  of  which  they  more  or  less  follow, 
suggesting  that  the  growth  has  originated  from  the  muscular  walls  of  these  ves- 
sels. In  other  parts  of  the  body,  myomata  are  also  sometimes  found  in  the  walls 
of  the  blood-vessels,  particularlj^  the  veins.  Some  of  the  myomata  of  the  skin 
have  been  shown  to  be  derived  from  the  arrectores  pilorum.  Now  and  then  epi- 
thelial elements,  in  the  form  of  cell  masses  or  imperfect  acini,  have  been  foimd  in 
uterine  myomata.  They  have  been  variously  explained  as  being  remnants  of  the 
Muellerian  or  Gaertner's  ducts,  or  of  the  Wolffian  body.  Possibly,  they  are  only 
portions  of  the  uterine  mucosa  which  have  been  pinched  off  and  have  become 
embedded  in  the  tumor. 

The  clinical  results  produced  by  myomata  depend  mainly  upon  their  size  and 
position.  Myomata  of  the  uterus  lead  to  distortion  and  displacement  of  that 
organ,  and  to  pressure  or  tension  on  the  other  pelvic  viscera.  Myomata  of  the 
prostate  often  start  from  the  so-called  middle  lobe,  and  may,  by  encroaching 
upon  the  urinary  passage  at  the  neck  of  the  bladder,  result  in  obstruction  to 
the  outflow  of  urine  with 'all  that  this  condition  implies.  (Fig.  94.)  Multiple 
myomata  of  the  skin  are  occasionally  very  painful  (tubercula  dolorosa). 

In  rare  instances,  leiomyomata  undergo  sarcomatous  transformation  and  give 
rise  to  metastases. 

Angiomata. 

Under  this  caption  are  included  a  number  of  tumors  and  tmnor-like  forma- 
tions the  chief  peculiarity  of  which  is  that  they  are  composed  mainly  of  vas- 
cular channels,  either  blood  or  lymph  vessels.  These  vessels  may  be  newly 
formed,  or  may  consist  of  the  pre-existing  vessels  of  the  part  more  or  less  altered, 
either  in  the  direction  of  enlarged  calibre,  or  in  that  of  increase  in  length  or 
hypertrophy  of  their  walls.  Tumors  consisting  mainly  of  blood-vessels  are 
termed  hoemangiomata,  or  angiomata,  this  term  being  used  in  a  restricted  sense; 
those  composed  of  lymph  channels  are  known  as  lymphangiomata. 

A  hsemangioma  consists  of  arteries,  capillaries,  and  veins,  which  are  sup- 
ported and  held  together  by  connective  tissue  or  by  tissues  homologous  with  it, 
such  as  adipose  and  mucoid  tissue.  We  can,  therefore,  recognize  mixed  forms 
of  vascular  tumors,  such  as  teleangiedatic  fibroma,  lipoma,  myxoma.     When  we 


320  AMERICAN  PRACTICE  OF  SURGERY. 

have  a  cellular  variation  Ln  the  direction  of  malignancj',  we  may  speak  of  angio- 
sarcoma. 

According  to  the  character  of  the  vessels  that  go  to  make  up  the  tiunor,  it  is 
customary  to  distmguish  several  subvarieties. 

In  hoemangioma  simplex  (hsemangioma  teleangiectaticum ;  teleangiectasia) 
there  is  an  excessive  development  of  capillaries,  with  a  relatively  scanty  forma- 
tion of  arteries  and  veins. 

Ho'mangioma  arteriale  (tumor  vasculosus  arterialis)  is  mainly  composed  of 
small  arteries,  with  a  relatively  small  proportion  of  capillaries  and  veins. 

Hcemangioma  cavernosum  (cavernoma ;  tumor  cavernosus)  presents  numerous 
large  vascular  spaces  or  sinuses,  lined  with  endothelium,  resembling  the'  struc- 
ture found  normally  in  the  corpora  cavernosa  of  the  penis. 

The  best  known  example  of  the  simple  hgemangioma  is  the  nmvus  vasculosus, 
one  of  the  forms  of  "birth-mark."  This  is  found  commonly  in  the  skin  and  is 
present  at  birth,  though  it  may  attain  its  greatest  development  somewhat  later. 
In  these  cases  we  caimot  always  speak  of  the  condition  as  a  true  tumor,  for  the 
vascular  area  may  be  badly  defined,  without  any  elevation  of  the  skin,  but  in 
other  instances  the  area  is  well  localized,  penetrating  into  the  subcutaneous  tis- 
sues, associated  with  undoubted  new  formation  of  fibrous  tissue,  and  covered 
with  hypertrophic  epithelium.  In  still  other  cases  regular  warts  or  flattened 
tubercles  are  formed. 

The  simple,  smooth  ntevus  appears  in  the  skin  as  a  bright  red  (ncemis  f.am- 
meus)  or  bluish-red  patch  (nsevus  vinosus:  "port-wine  stain").  At  the  periph- 
ery, many  smaller  vascular  spots  may  often  be  seen.  The  red  color  is  due  to 
the  presence  of  mmierous  wide  and  dilated  vessels  filled  with  blood,  situated 
partly  in  the  corium  and  partly  in  the  subcutaneous  fatty  tissue.  Occasion- 
ally, similar  formations  are  met  with  in  other  structures,  such  as  the  mamma, 
liver,  bones,  brain,  and  spinal  cord.  The  abnormality  consists  mainly  in  a  cir- 
cumscribed dilatation  of  pre-existing  or  newly  formed  capillaries.  The  dilatation 
may  be  spindle-shaped  or  cylindrical,  or,  again,  saccular,  or  all  three.  The  dilated 
vessels  may  be  separated  from  one  another  by  normally  constituted  capillaries 
or  by  capillaries  only  slightly  dilated.  The  vascular  walls  are  usually  thin,  or 
at  any  rate  not  specially  thickened. 

In  the  variety  of  simple  hsemangioma  known  as  the  angioma  simplex  hypei-- 
trophicum  the  capillaries  are  exceedingly  numerous  and  held  together  by  rela- 
tively little  connective  tissue.  The  lumina  of  the  vessels  are  only  moderately 
dilated  and  the  walls  are  thick  and  cellular,  resembling  arterial  walls.  In  a  few 
cases  it  happens  that  the  endothelial  cells  proliferate  and  thereby  encroach  on 
the  lumina.  The  tumor  is  divided  into  lobules  by  connective  tissue  in  such  a 
way  that  each  lobule  is  made  up  of  a  highly  convoluted  tangle  of  capillaries  with 
thickened  walls.  Here  and  there  atrophied  remains  of  sweat  glands  may  be 
sometimes  detected. 


TUMORS  AND  TUMOR  FORMATION.  321 

The  hoemangioma  venosum  is  composed  chiefly  of  veins,  the  capillaries  being 
only  slightly  if  at  all  enlarged.  The  dilatation  of  the  veins  is  cylindrical,  am- 
puUiform,  or  saccular.    The  vascular  walls  are  sometimes  thickened. 

The  hoemangioma  arteriale  consists  of  numerous  small  arteries,  with  a  com- 
paratively small  development  of  veins  and  capillaries.  A  curious  variety  of  this 
is  the  angioma  arteriale  racemosum  (cirsoid  aneurysm ;  angioma  arteriale  plexi- 
forme;  Rankenangiom).  Here  the  arteries  of  a  particular  district,  such  as  the 
forehead  or  scalp,  are  dilated,  thickened,  and  highly  convoluted.  The  tumor 
feels  on  palpation  somewhat  like  a  bag  of  worms.  The  blood  can  usually  be 
squeezed  out  of  the  vessels,  but  they  quickly  fill  up  again  so  soon  as  the  pressiu-e 
is  removed.     A  bruit  can  usually  be  heard  over  the  affected  area. 

The  cavernoma  (tumor  cavernosus)  consists  of  large,  irregularly  shaped 
sinuses,  lined  with  endothelium,  and  separated  one  from  the  other  by  a  more  or 
less  cellular  connective  tissue.  The  various  blood  spaces  may  here  and  there  be 
3een  to  communicate  with  one  another. 

Cavernomata  are  found  usually  in  the  skin  and  subcutaneous  tissues,  but 
occasionally  m  the  viscera,  especially  the  liver  (Fig.  95),  more  rarely  in  the 
kidney,  spleen,  uterus,  intestine,  bladder,  muscles,  and  bones.  In  the  skin  they 
form  bluish-red,  somewhat  elevated  or  warty  elevations  {mcvus  prominens),  or 
may  lead  to  a  uniform  and  extensive  enlargement  of  the  part,  constituting  one 
form  of  elephantiasis. 

The  histogenesis  of  hsemangiomata  is  extremely  interesting.  Many  of  the 
cases  are  present  at  birth  or  appear  during  the  earlier  years  of  life,  and  are  met 
with  in  situations  corresponding  to  the  embryonic  lines  of  fusion,  such  as  the  fa- 
cial and  branchial  clefts.  The  angiomata  foimd  at  the  orifices  of  the  body,  in  the 
face,  neck,  and  upper  part  of  the  breast,  are  of  the  nature  of  fissural  angiomata. 
Certain  of  the  naevi  vasculosi,  or  "mother's  marks,"  though  not  all,  come  under 
the  category  of  fissural  angiomata.  Many  of  the  angiomata  belonging  to  this 
class  are  at  first  little  more  than  teleangiectases,  but,  after  a  more  or  less 
prolonged  period  of  latency,  they  may  increase  in  size,  and  m  time  be  trans- 
formed into  large  projecting  masses,  resembling  a  cock's  comb. 

Other  htemangiomata  appear  to  have  some  connection  with  the  nervous  mech- 
anism {neuropathic  angiomata).  Such  are  the  teleangiectases  which  begin  as 
small  red  spots  on  the  skin  and  then  gradually  spread  over  the  surface  in  an  area 
corresponding  to  the  peripheral  distribution  of  some  cutaneous  nerve. 

Certain  multiple,  nodular  hsemangiomata  are  occasionally  met  with  in  old 
people,  and  are  often  termed  senile  angiomata.  Thoma  would  place  the  caver- 
noma of  the  liver,  which  also  occurs  in  advanced  life,  in  this  group. 

Traumatism  is  an  important  factor  in  some  cases.  Of  this  nature  are  some 
cicatricial  tumors  or  keloids  which  appear  after  injury  and  are  particularly  rich 
in  vessels. 

VOL.  I.— 21 


322 


AMERICAN  PRACTICE  OF  SURGERY. 


It  must  be  admitted  that  the  above  classification  of  the  angiomata  is  by  no 
means  complete,  for  many  forms,  and  not  the  least  important,  such  as  certain 
vascular  tumors  of  the  skin,  muscles,  glands,  and  intestines,  cannot  be  explained 
on  the  grounds  mentioned.  Possibly  here  congenital  anomalies  of  development, 
though  this  is  a  simple  conjecture,  may  have  to  be  taken  into  account. 

Thoma  has  drawTi  attention  to  the  important  part  that  physical  and  mechan- 
ical principles  play  in  determining  the  origin  and  development  of  angiomata. 
This  investigator  has  shown  that  the  new  formation  of  capillaries  is  related  to  the 
blood-pressure  within  the  capillaries  of  a  part  and  to  the  condition  of  the  sur- 
roimding  tissues.  The  normal  intravascular  pressure  is  dependent  on  the 
strength  of  the  cardiac  impulse  and  the  resistance  of  the  extravascular  tissues. 
An  increase  of  pressure  so  that  it  exceeds  the  normal  will  result  m  the  production 


Fig.  95. — Cavernous  Angioma  of  the  Li^cr.  Winekel  No.  3,  without  ocular.  Normal  liver 
tissue  is  shown  above  and  to  the  left.  The  fibrous  trabeculaj  of  the  blood  tumor  are  well  seen. 
(From  the  author's  collection.) 

of  new  capillaries.  This  may  be  explained  as  an  attempt  on  the  part  of  the  tis- 
sues to  establish  an  equilibrium.  Disturbances  of  the  blood  pressure,  as  can 
readily  be  understood,  might  easily  be  brought  about  by  errors  of  development 
and  derangements  of  the  vasomotor  mechanism.  Further  changes  are  depend- 
ent on  the  rate  of  the  blood  flow.  If  the  rate  be  under  the  normal,  capillaries 
with  narrow  limiina  are  formed  ;  if  it  be  greater,  the  capillaries  will  become 
more  or  less  dilated.  The  rise  in  blood  pressure,  which  must  occur  at  some 
time  in  the  process,  will  lead,  m  accordance  with  well-known  pathological  prin- 
ciples, to  increase  in  the  thickness  of  the  capillary  and  lesser  arterial  walls. 

The  lym-phangioma,  or  angioma  lymphaticitm,  is  m  most  respects  analogous  to 
the  hemangioma,  save  that  the  vascular  spaces  contained  therein  are  lymph 


TUMORS  AND  TUMOR  FORMATION.  323 

channels  instead  of  blood-vessels.  The  supporting  stroma  in  which  the  vessels 
are  embedded  may  be  fibrous,  fatty,  or  mucinous. 

Three  anatomical  forms  are  recognized :  the  Ixjmphangioma  sim-plex  or  telean- 
giectasia lymphatica,  the  lymphangioma  cavernosum,  and  the  lymphangioma  cys- 
toides. 

In  simple  lymphangioma  the  lymphatic  vessels  in  a  more  or  less  circum- 
scribed area  are  dilated  and  their  walls  thickened.  In  the  cavernous  variety  the 
lymph  channels  are  very  numerous  and  much  dilated,  so  that  the  structure,  on 
section,  has  a  somewhat  spongy  texture.  The  supporting  stroma  is  scanty,  thin, 
delicate,  and  transparent.  In  the  last-mentioned  form  cysts  varying  in  size  from 
that  of  a  pea  to  that  of  a  walnut  or  larger  may  be  produced. 

As  in  the  case  of  the  htemangiomata,  developmental  anomalies  are  of  great 
etiological  moment.  Many  of  the  lymphangiomata  are  fomid  in  connection  with 
the  sutures  and  fissures  of  the  body.  Of  this  nature  are  the  lymphangiectasias 
met  with  in  the  tongue  (macroglossia) ,  gums,  lips  (macrocheilia),  neck  (hygroma 
colli  congenitum),  skin  (ncevus  lymphaticus) ,  subcutaneous  tissues,  and  vulva.  A 
diffuse  cavernous  dilatation  of  the  lymphatic  channels  of  the  skin  or  subcuta- 
neous tissues,  as,  for  instance,  in  the  thigh  and  scrotum,  gives  rise  to  one  form  of 
elephantiasis.  Some  of  the  lymphangiectases  of  the  skin,  subcutaneous  tissues, 
peritoneum,  and  mesentery,  appear  late  in  life  and  are  acquired  rather  than  con- 
genital. Lymphangiomata  of  the  mesentery  contain  chyle  and,  hence,  are  some- 
times called  chylangiomata.  Cystic  lymphangiomata  are  sometimes  met  with  m 
the  peritoneum,  but  are  rare.  Some  authorities  would  class  certain  of  the  pig- 
mented nsevi,  pigment  patches,  freckles,  and  fleshy  warts  with  the  lymphangi- 
omata. 

Lymphangiomata  in  the  course  of  their  growth  may  extend  widely  and  dis- 
locate or  enclose  portions  of  the  neighboring  tissues.  They  may  reach  the  surface 
of  the  body  and  there  discharge,  forming  lymph  fistulse  and  causing  lymphor- 
rhoea. 

Both  the  hfemangiomata  and  the  lymphangiomata  are  to  be  classed  with  the 
benign  growths.  As,  however,  they  contain  newly-formed  endothelial  elements 
and  connective  tissue,  we  occasionally  find  that  they  take  on  malignant  action, 
becoming  extremely  cellular  (perithelial  or  endothelial  angiosarcoma). 

Lymphangiomata  may  attain  a  considerable  size,  and  the  cavernous  and  cystic 
forms  are  often  multiple.  On  section,  these  tumors  exude  lymph,  which  may  be 
clear,  or  cloudy  from  admixture  with  lymph  corpuscles  or  blood.  The  contents 
of  the  cysts  may  be  fluid,  or,  again,  partially  or  completely  coagulated. 

Histologically,  the  lymph  spaces  are  lined  with  endothelimn  and  held  to- 
gether by  a  rather  cellular  fibrous  tissue.  Almost  any  tissue  may,  however,  at 
times,  enter  mto  the  composition  of  the  stroma.  Here  and  there  m  the  support- 
ing substance  collections  of  lymphoid  cells  may  be  fomid. 


324  AMERICAN  PRACTICE  OF  SURGERY. 

Gliomata. 

Gliomata  are  tumors  derived  from  the  neuroglia  or  supporting  stroma  of  the 
central  nervous  system.  The}'  are  limited,  therefore,  to  the  brain  and  cord,  and 
to  those  parts  of  the  peripheral  nervous  system  which  represent  prolongations  of 
the  primitive  cerebral  vesicles,  namely,  the  retina,  optic  nerve,  and  olfactory  bulbs. 

Gliomata  may  be  single  or  multiple,  and  vary  considerably  m  size,  though 
they  never  become  very  large.  As  a  rule  they  resemble  more  or  less  closely  the 
nervous  tissue  in  which  they  are  found,  and  indeed  cases  are  not  infrequently  met 
with  where  we  are  onh'  able  to  infer  the  presence  of  a  tumor  from  the  fact  that 
there  is  a  local  swelling  of  the  brain  substance  and  that  the  normal  distinctions 
between  the  various  parts  of  the  organ  are  obliterated. 

On  section  through  a  glioma  we  find  that  it  is  usually  badly  defined,  infiltrat- 
ing the  surrounding  tissues;  it  is  sometimes  grayish  in  color,  moderately  firm 
and  somewhat  translucent,  resembling  the  normal  gray  matter  of  the  central 
nervous  system;  it  may  be  grayish-white,  rather  dense  and  hard;  or,  again,  it 
may  be  grayish-red  or  dark  red,  owing  to  the  presence  of  numerous  vessels. 
Hemorrhage  into  the  substance  of  the  tumor,  fatty  degeneration,  softening,  and 
necrosis  are  not  infrequent  accompaniments. 

Histologically,  ,a  typical  glioma  is  composed  of  a  meshwork  of  delicate  refrac- 
tile  fibrils,  among  which  can  be  seen  embedded  more  or  less  numerous  rounded 
or  oval  nuclei.  These  nuclei,  on  closer  inspection,  are  found  to  be  surroimded 
by  a  small  quantity  of  cell  protoplasm  (Fig.  96).  On  macerating  the  tissue  and 
teasing  it  out  with  needles  the  cells  referred  to  can  be  shown  to  be  bipolar  and 
stellate  in  shape  and  to  possess  shorter  or  longer,  sometimes  branching,  processes. 
The  blood-vessels  are  often  abundant  and  may  be  dilated  {glioma  teleangi- 
ectaticum).  The  relative  proportions  of  cells  and  fibrils  vary  in  different 
cases.  Some  gliomata  are  cellular  (glioma  moUe),  others  are  more  fibrous  [glioma 
durum). 

We  can  better  understand  the  histogenesis  of  the  gliomata  if  we  remember 
the  way  in  which  the  neuroglia  normally  develops.  The  glia,  like  the  specific 
nerve  elements,  is  of  ectodermic  origin,  being  derived  from  the  undifferenti- 
ated epiblastic  cells  heaped  up  about  the  primitive  dorsal  groove.  These  cells 
eventually  are  separated  from  the  superficial  ectoderm  and  become  aggregated 
about  a  central  space,  the  neural  canal,  which  is  Imed  with  cells  that  permanentl}' 
retain  their  epithelial  type.  Wliile  certain  cells  undergo  marked  differentiation, 
and  eventually  are  converted  mto  the  highly  complicated  nerve  structures,  others 
remain  more  primitive  and  assume  many  of  the  characteristics  of  connective 
tissue.  The  latter,  the  glia  cells,  originate,  both  in  the  highest  and  lowest  ver- 
tebrates, in  the  ependyma  cells,  which  are  now  known  to  belong  to  the  supporting 
structures.  In  certain  of  the  more  primitive  animals,  such  as  the  amphioxus, 
the  supporting  stroma  is  composed  entirely  of  ependymal  cells,  but  higher  in 
the  scale  we  find  that  the  principal  part  is  taken  by  stellate  cells  (astrocytes).     In 


TUMORS  AND  TUMOR  FORMATION.  325 

the  case  of  mammals  it  is  believed  by  some  that  the  astrocytes  are  not  derived 
directly  from  the  ependymal  cells,  but  from  intermediate  forms,  which  may  be 
termed  astroblasts.  All  glia  cells,  whether  provided  with  long  or  short  processes, 
brush  cells  or  stellate  cells,  are  therefore,  ultimately  derived  from  the  same  pre- 
cursors. 

It  has  usually  been  taught  that  the  various  processes  are  closely  related  to  the 
cell  bodies,  being,  in  fact,  protoplasmic  prolongations  of  the  latter,  an  opinion 
based  upon  studies  conducteil  with  the  Golgi  method  of  staining  More  recent 
methods,  notably  those  of  Weigert,  Mallory,  and  Beneke,  have  proved,  however, 
that  this  is  not  altogether  correct.     According  to  Weigert,  the  cells  of  human 


Fig.  96. — Glioma,  from  Cerebral  Cortex.      Winckel  No.  6,  without  ocular.      (From  the  author's 

foUection.) 

neuroglia  possess  protoplasmic  processes  only  during  embryonic  life.     Adult 
neuroglia  is  made  up  of  cells  and  fibrils,  the  latter  greatly  predominating. 

Bearing  these  facts  in  mind  we  are  able  to  get  a  more  adequate  conception  of 
the  various  forms  of  gliomata  that  we  actually  meet  with.  Thus,  we  have:  (1) 
The  glioma  durum,  or  fibrillary  form,  corresponding  to  mature  glial  tissue;  (2)  the 
astrocytic  glioma,  composed  of  Deiters'  spider  and  brush  cells;  (3)  a  highly  cel- 
lular form,  resembling  a  small  round-celled  sarcoma,  possibly  derived  from  a  still 
more  undifi'erentiated  type  of  cell,  namely,  the  astroblast;  (4)  gliomata  composed 
of  cells  of  ependymal  type.  It  must  be  admitted,  however,  that  while  the  more 
recent  methods  of  investigation  have  proved  of  great  value  in  differentiating  the 
various  forms  of  glioma  one  from  the  other,  in  another  direction  they  have  per- 
haps proved  more  confusing  than  helpful,  for  the  relationship  of  such  conditions 
as  sclerosis  of  the  central  nervous  system,  nodular  gliosis,  and  the  central  gliosis 
of  syringomyelia  remains  still  cjuite  obscure. 


326  AMERICAN  PRACTICE  OF  SURGERY. 

A  word  or  two  with  regard  to  the  ghomata  of  the  retina  may  not  be  out  of 
place.  These  tumors  are  met  with  only  in  childhood,  usually  in  the  earlier  years. 
One  or  both  eyes  may  be  attacked,  and  more  than  one  member  of  a  family  may 
be  affected  with  the  disease.  The  timior  may  originate  in  any  of  the  layers  of  the 
retina,  but  usually  in  the  deeper  parts.  It  grows  more  or  less  rapidly,  extends 
forward  into  the  vitreous  humor  and  invades  the  uveal  region,  or  it  may  perforate 
the  sclerotic  posteriorly  and  attack  the  orbit  and  brain.  Eventually,  the  whole  eye 
is  destroyed  and  we  have  a  large  vascular,  fmigating  mass  which  projects  exter- 
nally and  leads  to  destruction  of  the  neighboring  soft  tissues  and  bone.  Second- 
ary growths  are  formed  in  the  regional  lymph  nodes  and  in  distant  organs.  _  His- 
tologically, we  may  recognize  several  varieties,  which  are  strictly  in  accord  with 
the  classification  of  the  other  gliomata  indicated  above.  The  most  common  form 
is  a  highly  cellular  growth,  composed  of  midifferentiated  cells,  resembling  closely 
the  small  round-celled  sarcoma.  Less  often  the  growth  is  composed  of  closely 
aggregated  cells  with  processes,  or  astrocytes.  In  other  cases  we  find  curious 
rosette-like  formations,  so  that  the  tirnior  resembles  in  some  degree  the  cells  of 
the  layers  of  rods  and  cones.  The  layer  of  rods  and  cones  corresponds  histoge- 
netically  with  the  epithelial  cells  lining  the  central  neural  canal,  and,  therefore, 
is  to  be  regarded  as  of  ependymal  nature.  Flexner,  therefore,  would  term  such 
tumors  ependymal  gliomata.  In  consideration  of  their  histological  appearance 
and  the  physiological  function  of  the  cells  from  which  they  are  derived,  they 
are  often  called  yieuro-epitheliomata. 

The  relationship  of  glioma  to  sarcoma  is  at  present  a  somewhat  debatable 
question.  The  fact  that  gliomata  are  embryologically  of  ectodermic  origin,  while 
sarcomata  are  mesodermic,  would  of  itself  suffice  to  indicate  that  there  are  fimda- 
mental  differences  between  these  two  forms  of  new  growth.  It  is  a  fact,  how- 
ever, that  the  vessels  in  gliomata  are  provided  with  sheaths  of  mesoblastic  fibrous 
tissue,  and  it  is,  therefore,  theoretically  possible  that  a  cellular  variation  of  this 
mesoblastic  structure  might  on  occasion  give  rise  to  a  true  sarcomatous  neopla- 
sia. Such  tumors  would,  therefore,  be  mixed  m  character,  consisting  both  of 
newly  formed  glial  and  sarcomatous  elements.  As  we  have  seen,  however,  cer- 
tain gliomata  are  derived  from  relatively  imdifferentiated  glial  cells,  and  their 
resemblance  to  romid-celled  sarcomata  is  so  close  that  we  are  often  at  a  loss  to 
make  the  differential  diagnosis.  This  being  the  case,  we  are  hardly  justified,  in 
my  opinion,  in  speaking  of  new  growths  of  this  histological  tj'pe  as  "glio-sarco- 
mata,"  even  in  view  of  the  fact  that  they  are  often  malignant.  \^^ien  we  con- 
sider that  tmnors  of  this  type  are  composed  of  relatively  undifferentiated  cells, 
cells  which  according  to  well-known  pathological  prmciples  must  be  endowed 
with  great  proliferative  capacity,  it  is  not  surprising  that  they  at  times  take  on 
excessive  and  aberrant  action.  This  view  is  supported  by  what  we  have  already 
learned  in  connection  with  other  tumors  composed  of  relatively  immature  cells, 
such  as  the  soft  fibroma,  myxoma,  and  chondroma,  which,  as  we  have  seen,  may 


TUMORS  AND  TUMOR  FORMATION.  327 

occasionally  produce  both  local  and  distant  metastases.  We  shall,  I  think,  be 
more  logical  if,  for  the  time  being  at  least,  we  speak  of  the  forms  in  question  as 
"malignant  gliomata,"  until  microscopical  investigation  shall  have  proved 
beyond  cavil  that  the  round  cells  present  therein  are  derived  from  the  meso- 
blastic  vessel  sheaths. 

Some  interesting  points  come  up,  too,  in  regard  to  the  ependymal  gliomata. 
It  cannot  now  be  denied  that  we  occasionally  meet  with  tumors  composed  of 
cells  resembling  somewhat  closely  cells  of  ependymal  type.  Flexner,  for  exam- 
ple, records  a  brain  tumor  composed  of  cells  resembling  for  the  most  part  the 
ependymal  cells  found  in  the  embryonic  human  cord.  These  cells  were  arranged 
in  a  radial  fashion  around  the  blood-vessels,  toward  which  their  processes  were 
directed.  The  processes  came  together  at  a  point  somewhat  short  of  the  vessel 
wall,  so  that  a  small  space  existed  between  them  and  the  wall.  It  is  conceivable 
that  more  fully  developed  or  adult  ependymal  cells  might  be  competent  to  give 
rise  to  tumors.  One  point  to  which  attention  should  be  directed  is  that  the  cells 
of  the  ependymal  gliomata  may  assume  more  or  less  perfectly  an  epithelioid  type. 
In  cases  where  the  cells  are  of  this  character,  or  are  spindle-shaped,  especially  if 
they  be  grouped  about  the  vessels,  the  resemblance  to  the  endotheliomata  and 
peritheliomata  is  striking.  With  regard,  therefore,  to  tumors  originating  in  por- 
tions of  the  brain  containing  ependymal  elements,  as  for  instance  the  pituitary, 
which  resemble  endothelial  and  perithelial  formations,  it  would  be  well  always  to 
consider  the  possibility  of  their  being  glial  and  ependymal  in  nature. 

It  is  quite  possible  that  the  gliosis  occurring  in  the  condition  known  as  syrin- 
gomyelia, which  has  proved  such  a  puzzle  to  investigators,  may  be  explained  on 
the  lines  indicated  above.  Flexner  {Journal  of  Nervous  and  Mental  Disease,  May, 
1898)  mentions  having  seen  a  case  of  syringomyelia  in  which  the  tumor  mass  was 
composed  largely,  if  not  entirely,  of  cells  of  an  early  ependymal  type. 

In  view  of  the  fact  that  our  ideas  in  regard  to  gliosis  and  gliomatosis  are  in  a 
transition  stage,  and  that  our  ignorance  on  many  important  points  is  not  slight,  it 
is  not  surprising  that  but  little  is  to  be  said  on  the  subject  of  the  remote  etiology 
of  these  growths.  Certain  of  the  ependymal  gliomata,  and  the  gliomata  met 
with  in  childhood,  are  probably  to  be  referred  to  some  developmental  anomaly 
or  aberration.  Trauma  has  been  held  by  some  to  play  a  part.  Possibly,  also, 
toxic  and  infectious  agents  will  be  found  to  be  of  some  etiological  importance. 

Gliomata  produce  their  effects  in  accordance  with  their  size  and  position. 
Those  in  the  central  portion  of  the  brain  give  rise  to  no  clinical  symptoms 
save  those  of  pressure.  Others,  when  situated  in  areas  functionally  important, 
both  by  pressure  and  destructive  infiltration  damage  the  neurons  and  interfere 
proportionately  with  the  origination  and  conduction  of  impulses.  Thus  we  may 
get  muscular  paralysis,  disturbances  of  sensation,  interference  with  muscular 
tone,  pain,  and  paresthesia;. 


328  AMERICAN  PRACTICE  OF  SURGERY. 

Neuhoxiata. 

The  term  neuroma  is  used  somewhat  loosely  b}'  surgeons  to  designate  almost 
any  tumor  arising  in  connection  with  nerves.  In  this  category  would  come  the 
so-called  "amputation  neuroma,"  multiple  cutaneous  neuromata,  and  the  plexi- 
form  neuroma.  To  which  may  possibly  be  added  the  neuroma  or  neuro-glioma 
ganglionare.  All  these  forms  have  this  in  common,  that  they  consist  of  nerve 
cells  or  fibres  held  together  by  a  fibrous  or  neuroglial  matrix.  It  should  be  re- 
marked, however,  that  in  the  strict  sense  of  the  term  the  word  "  neuroma  "  should 
be  applied  only  to  growths  consisting  wholly  or  in  part  of  newly  formed  nerve 
elements.  Of  course  it  is  difficult  in  many  cases  to  decide,  when  nerve  cells  or 
fibres  are  discovered  in  a  tumor,  whether  these  are  newly  formed  or  not,  and  this 
is  the  whole  point  at  issue  between  the  pathologists.  A  large  number  of  growths 
occupy  debatable  ground,  but  more  careful  study,  connected  with  modern  tech- 
nique, has  served  greatly  to  circumscribe  the  class  of  nerve  tumors,  though  it  has 
undoubtedly  proved  that  neuromata,  in  the  true  sense  of  the  word,  do  exist. 

The  so-called  amputation  neuroma  belongs  to  what  has  been  called  the  trau- 
matic neuromata.  It  is  perhaps  the  most  common  form  of  the  false  neuromata. 
As  its  name  implies,  the  condition  is  found  in  connection  with  amputation  wounds. 
In  some  cases  of  this  kind  the  ends  of  the  nerves  within  the  stump  are  found 
to  be  swollen  like  clubs  and  firmly  adherent  to  the  cicatrix.  Microscopic  exam- 
ination shows  that  these  nodes  are  composed  of  medullated  and  non-medullated 
nerve  fibres,  irregularly  interlacing,  embedded  in  a  dense  scar  tissue.  Properly, 
such  growths  should  not  be  classed  with  the  neuromata,  for  they  represent  sim- 
ply the  ordinary  process  of  regeneration  modified  by  an  unusual  physical  condi- 
tion. The  dense  scar  prevents  the  nerve  fibres  from  growing  straight  forward 
in  the  axis  of  the  nerve  trunk,  so  that  they  become  diverted  and  bend  and  inter- 
lace in  a  confused  manner.  The  new  formation  of  fibres  is,  therefore,  not  au- 
tonomous. Traumatic  neuromata  are  occasionally  met  with  in  connection  with 
injuries  other  than  amputation.  Division  or  compression  of  a  nerve  sometimes 
results  in  the  formation  of  nodules  composed  of  newly  formed  nerve  fibres  and 
connective  tissue  at  the  seat  of  injuiy. 

An  interesting  class  of  cases  is  that  which  includes  the  nuiltiple  nodes  some- 
times found  upon  the  peripheral  nerves.  These  tumors  are  found  not  only  on 
the  trunk  of  the  nerves,  but  also  on  their  peripheral  terminations  and  may  affect 
a  large  part  of  the  body,  or,  again,  may  be  confined  to  a  particular  nerve  dis- 
trict. Not  uncommonly  the  tumors  are  situated  in  the  skin  where  they  form 
numerous,  smaller  or  larger,  visually  soft  nodules.  They  are  often  painful,  ow- 
ing to  pressure  upon  the  sensorj^  fibres  (tubercula  dolorosa).  Further  investiga- 
tion has  shown  that  some  of  these  cutaneous  nodules  are  leiomyomata  containing 
nerve  fibrils,  but  the  majority  of  them  are  to  be  regarded  as  fibromata  (q.  v.). 
The  smallest  nodules  are  only  of  microscopic  size,  but  the  larger  ones  may  attain 
the  size  of  a  pea,  a  marble,  or  even  a  man's  fist. 


TUMORS  AND  TUMOR  FORMATION.  329 

The  so-called  plexiform  neuroma  (Rankenneurom)  has  already  been  tlealt 
with  (see  p.  305).  Suffice  it  to  say  here  that  mo.st  authorities  hold  it  to  be 
simply  a  peculiar  form  of  fibroma  of  the  nerve  sheaths,  though  a  few  good  ob- 
servers still  maintain  that  the  nerve  fibres  to  be  seen  in  this  growth  are  newly 
formed,  and  that,  therefore,  the  tumor  is  a  true  neuroma.  Plexiform  neuromata 
are  found  upon  the  head,  trunk,  and  extremities,  and  lead  to  a  condition  re- 
sembling elephantiasis. 

The  multiple  cutaneous  neuromata  found  by  Knauss  in  j'oung  children  seem 
to  be  true  neuromata.  Here  we  find  branching  ganglion  cells  together  with 
numerous  medullated  and  non-medullated  fibres,  having  no  anatomical  conti- 
nuity with  the  nerves  of  the  part. 

"Neuromata"  of  the  central  nervous  system  have  been  described.  In  some 
of  these,  tumor-like  masses  of  nervous  substance  have  been  found.  Probably 
some  of  them  are  simply  a  misplacement  or  abnormal  arrangement  of  the  normal 
layers  of  the  central  nervous  tissues,  due  to  an  anomaly  of  development.  Or 
they  may  be  merely  artefacts,  as  Lubarsch  has  suggested.  Inasmuch  as  certain 
of  the  forms  just  mentioned  contain  ganglion  cells,  they  have  been  included  with 
the  neuro-glioma  or  neuroma  ganglionare. 

Ganglionic  neuromata  have  been  met  with  in  the  thoracic,  lumbar,  hypogas- 
tric, solar,  and  adrenal  plexuses  of  the  sympathetic  system.  Microscopically, 
they  consist  of  a  more  or  less  dense  glia-supporting  stroma,  in  which  can  be 
seen  irregularly  distributed  ganglia,  and  nerve  fibres.  They  are  probably  true 
neuromata. 

Papillo.m.\ta. 

Strictly  speaking,  the  term  "  papilloma,"  as  applied  to  tumors,  refers  to  their 
external  appearance  rather  than  to  peculiarities  of  histogenetic  structure.  Any 
tumor,  in  fact,  which  projects  above  the  general  surface  of  the  tissue  in  which  it 
is  found,  and  has  a  convoluted,  villus-like  appearance,  may  properly  be  termed 
a  papilloma.  Such  tumors  illustrate  particularly  well  the  "organoid"  character 
supposed  to  appertain  to  the  benign  growths  we  have  been  describing. 

Papillomata  consist  of  a  central  core  of  vascular,  connective,  or  mucoid  tis- 
sue, covered  with  one  or  more  layers  of  epithelium.  They  are  found  springing 
from  the  skin  and  mucous  surfaces  and  occasionally  from  the  interior  of  cysts 
and  the  ducts  of  glands.  They  are' rounded,  cylindrical,  lobulated,  or  cauliflower- 
like in  appearance,  or  highly  convoluted  and  villus-like.  They  may  be  sessile 
and  attached  by  a  broad  base,  or,  again,  may  have  a  relatively  narrow  pedicle. 
The  nature  of  the  epithelium  with  which  they  are  covered  varies  somewhat,  but 
conforms  more  or  less  closely  to  that  of  the  part  from  which  they  arise  (Fig.  97). 

Many  cutaneous  warts  belong  to  the  class  of  papillomata,  as  do  certain  con- 
genital excrescences  on  the  surface  of  the  body,  papillary  najvi. 

Papillomata  of  the  mucous  surfaces  are  found  especially  in  connection  with 


330 


AMERICAN  PRACTICE  OF  SURGERY 


the  larjqix  and  trachea,  the  stomach  and  intestines,  the  urinarj-  bladder,  and  the 

genitaha,  as,  for  example,  the  penis,  vulva,  vagina,  uterus,  and  Fallopian  tubes. 

One  of  the  most  important  types  is  the  papilloma  of  the  bladder,  which  takes 

the  form  of  a  cauliflower-like  growth,  composed  of  an  aggregation  of  numer- 


ous delicate  branching  papilUe.  These  papillse  are  composed  of  a  small  amount 
of  vascular  connective  tissue  covered  with  cjdindrical  epithelium.  Papilloniata 
of  the  bladder  are  usually  situated  at  the  fundus  of  the  organ  and  are  often  mul- 


TUMORS  AND  TUMOR  FORMATION.  331 

tiple.  They  are  of  importance  to  the  surgeon  in  that  thej'  frequentlj'  cause  ob- 
struction of  the  urine,  with  all  that  implies,  give  rise  to  ha^maturia,  and  may, 
occasionally,  assume  malignant  action. 

The  most  potent  single  factor  in  the  causation  of  papillomata  is  irritation  in  its 
widest  sense.  Papillomata  of  the  larynx  are  found  m  singers,  public  speakers, 
and  others  who  strain  the  voice.  Chronic  congestion  may  be  of  importance  here. 
Chronic  catarrh  accounts  for  many  papillomata  of  the  mucous  surfaces,  as,  for 
example,  "venereal  warts"  (condylomata  acuminata).  Many  of  the  warts  of 
the  skin  are  properly  to  be  referred  to  the  effects  of  irritation.  It  is  perhaps  ques- 
tionable, where  chronic  inflammation  is  the  chief  etiological  factor,  whether  the 
new  formation  of  tissue  thereupon  resulting  should  properly  be  classed  with  the 
autonomous  new  formations.  It  has  probably  more  affinities  with  the  simple, 
irritative  hyperplasias.  The  papillary  excrescences  found  in  connection  with 
many  cystic  adenomata  may  with  much  more  reason  be  classed  with  true  tumors. 

Sarcomata  (Atypical  Meso-hylomata). 

We  have  up  to  this  point  been  considering  a  series  of  neoplasms,  benign  in 
character  and  of  more  or  less  perfect  organoid  type,  which  have  this  in  comnron, 
that  they  reproduce  the  features  of  normal  adult  connective  tissue,  that  is  to  say, 
fibrous  tissue  and  its  homologues.  They  are  of  mesoblastic  origiii,  with  the  ex- 
ception of  the  neuromata  and  gliomata,  which  are  epiblastic,  and  the  papillomata, 
which  are  partly  mesoblastic  and  partly  epiblastic. 

Corresponding  with  most  of  these,  and  forming  a  cellular  variation  of  them, 
we  have  another  set  of  tumors,  commonly  known  as  sarcomata. 

Sarcomata  may  be  defined  as  malignant  tumors  of  mesoblastic  origin  and  con- 
nective-tissue type,  having  for  the  most  part  this  peculiarity,  that  they  are  com- 
posed of  cells  that  more  or  less  completely  fail  to  attain  the  morphological  perfec- 
tion of  adult  cells.  These  cells  are  immature  or  comparatively  undifferentiated  and 
are  consequently  endowed  with  great  proliferative  capacity.  We  find,  therefore,  as 
we  might  expect,  that  the  sarcomata  are  the  most  malignant  of  tumors,  that  is  to 
say,  they  grow  rapidly,  tend  to  recur  locally  after  removal,  form  early  and  exten- 
sive metastases,  and,  finally,  are  apt  to  break  down  and  ulcerate.  The  occur- 
rence of  local  metastases  accounts  for  the  lobulated  structure  that  so  many  sar- 
comata present. 

Sarcomata  arise  from  all  forms  of  connective  tissue  and  in  any  part  where 
such  structures  are  found.  They  develop,  therefore,  from  fibrous  tissue,  fatty 
tissue,  mucoid  tissue,  cartilage,  and  bone  (Fig.  98).  There  are  certain  parts, 
however,  where  they  are  more  conunon  than  elsewhere.  They  are  met  with 
oftener,  for  example,  in  the  skin,  fascia,  intermuscular  connective  tissue,  peri- 
ostexmr,  bone,  brain,  and  ovaries  than  in  the  lungs,  liver,  mtestines,  and  uterus. 

The  gross  anatomical  appearance  of  sarcomata  varies  considerably  according 
to  circumstances.    No  one  description  applies  to  all.  Many  sarcomata,  especially 


332  .AJilERiaiX   PRACTICE  OF  SURGERY. 

those  comiected  with  bone  and  periosteiun,  attam  a  large  size,  others  ai'e  almost 
microscopic.  In  color,  they  may  be  whitish,  pinkish,  or  grayish-white,  glistening 
and  semitranslucent,  at  other  tmies  bro\s'nish,  black,  bluish,  green,  or  slaty,  from 
the  deposit  of  pigment.     In  regard  to  consistence,  some  are  soft,  juicy,  and  bram- 


FiG.  98. — Sarcoma  of  the  Shaft  of  tlie  Humerus.      (.Pathological 
iluseum  of  ilcGill  ITniversity.) 

like  (mechiUarij  sarcomata);  others,  firmer,  denser,  and  more  fibrous;  still  others 
are  of  almost  stonj'  hardness. 

Blood-vessels  are  more  or  less  nimierous,  and  ma}-  be  dilated  {teleangiedatic 
sarcomata).  The  vessels  usuallj'  possess  a  regular  wall,  well  defined  from  the 
tumor  substance,  but  in  some  mstances  it  is  composed  of  the  proper  cells  of 
the  new  growth. 


TUMORS  AND  TUMOR  FORMATION.  333 

Retrogressive  changes,  fatty  and  mucoid  degeneration,  hemorrhage,  coHi- 
quative  necrosis,  caseation,  gangrene,  and  ulceration  are  not  uncommon. 

As  Ave  have  seen  in  the  preceding  pages,  not  a  few  of  the  benign,  so-called 
organoid  tumors  ma}-  on  occasion  undergo  at  some  point  or  other  malignant, 
that  is  to  say,  sarcomatous,  transformation.  We  may  thus  recognize,  on  the 
basis  of  etiology,  fibro-sarconiata,  lipo-,  myxo-,  chondro-,  osteo-,  osteoid,  and  angio- 
sarcomata.  The  sole  exceptions  are  the  neuromata  and  gliomata.  The  neuro- 
mata are  excessively  rare  and  not  well  understood,  but  so  far  as  we  know  have  no 
malignant  cellular  derivative.  A  malignant  form  of  glioma  is  known,  the  so- 
called  "glio-sarcoma,"  but  we  have  elsewhere  adduced  reasons  for  thudving  that 
the  majority  of  these  are  not  true  sarcomata,  unless  we  are  prepared  to  use  this 
term  in  the  widest  sense.  Sarcomata  may,  however,  arise  directly  from  con- 
nective tissues  without  passing  through  the  intermediate  stage  of  benign  neoplasia. 

For  descriptive  purposes  it  is  usual  to  classify  the  sarcomata  according  to  the 
character  and  arrangement  of  the  cells  composing  them.  Perhaps  the  arrange- 
ment adopted  by  Ziegler  is  as  convenient  as  any.  He  recognizes:  (1)  Simple  sar- 
comata, tumors  composed  of  a  uniform  aggregation  of  cells  of  connective-tissue 
type,  but  immature;  (2)  tumors  which,  owing  to  the  peculiar  arrangement  and 
grouping  of  their  component  parts,  more  closely  approxmiate  the  organoid  type, 
in  some  cases  resembling  tumors  of  definitely  epithelial  type;  and  (3)  tumors 
presenting  secondary  changes  in  their  specific  cells,  stroma,  or  blood-vessels, 
changes  that  give  them  a  peculiar  and  characteristic  appearance. 

Simple  Sarcomata. — The  simple  sarcomata  may  be  divided  according  to  the 
shape  of  their  cells  into  small  and  large  round-celled  sarcomata,  small  and  large 
spindle-celled  growths,  and  mixed  forms.  All  gradations  exist  between  the  soft, 
highly  cellular,  and  malignant  medullary  tumor  and  the  more  slowly  growing, 
firm,  fibrous  sarcoma.  At  one  end  of  the  scale  we  have  the  small  round-celled 
sarcoma,  at  the  other  the  fibro-sarcoma  and  recurrent  fibroma. 

Small  round-celled  sarcomata  are  found  more  especiall}-  arising  from  the  con- 
nective tissue  of  the  locomotor  apparatus  and  from  connective-tissue  stroma. 
They  are  met  with  also  in  the  skin,  lymph  nodes,  testis,  and  ovaries.  They  are 
soft  and  rapidly  growing.  On  section,  they  are  whitish  or  grayish-white  in  color, 
brainlike,  and  a  milky  juice  can  be  scraped  from  the  surface.  Not  infrequently 
they  present  necrotic,  caseated,  or  softened  areas. 

Histologically,  they  consist  almost  entirely  of  round  cells  and  blood-vessels. 
The  round  cells  are  small  and  delicate,  with  relatively  little  cytoplasm,  and  con- 
tain round  or  oA^ate,  somewhat  A^esicular,  nuclei.  (Fig.  99.)  BetAA'een  the  cells 
is  a  variable  quantity  of  delicate  granular  and  fibrillar  stroma.  It  is  usually 
quite  scanty  and  may,  indeed,  be  difficult  to  demonstrate.  The  A^essels  may  be 
recognized  as  thin-walled  channels  coursing  betAA^een  the  specific  cells  of  the  tu- 
mor. Here  and  there  lymphoid  cells  can  be  made  out  Avhose  nuclei  stain  more 
intensely  than  those  of  the  tumor  proper. 


334  AMERICAN  PRACTICE  OF  SURGERY. 

One  particular  form  of  small  round-celled  sarcoma  deserves  special  remark. 
This  is  the  so-called  lymphosarcoma.  It  is  very  difficult  to  place  this  tumor,  for 
pathologists  are  by  no  means  agreed  as  to  its  nature.  The  enlarged  lymph  nodes 
in  Hodgkin's  disease  are  bj'  some  regarded  as  the  result  of  a  true  autonomous  neo- 
plasia, thereupon  termed  lympho-sarcoma ;  others  think  that  the  condition  is  a 
simple  inflammatory  tissue  hyperplasia.  There  is,  undoubtedly,  a  new  growth  of 
the  lymph  nodes,  which  leads  to  local  infiltration  and  the  formation  of  distant  met- 
astases. It  has  the  microscopical  appearance  of  a  small  round-celled  sarcoma 
(Fig.  100).  Such  a  growth  might  arise  from  the  connective  tissue  of  the  nodes  (sar- 
coma of  the  lymph  nodes)  or  by  proliferation  of  the  lymphoid  elements  (true 
l}Tiipho-sarcoma) . 


Fig.  99. — Small  Round-Celled  Sarcom.a  oi  tlio  Cervix  Uteri.      Winckel  No.  6,  without  ocular. 
(From  the  author's  collection.) 

Large  rouml-celled  sarcomata  resemble  closely  the  small-celled  t3'pe  and  develop 
in  the  same  situations.  They  are  somewhat  firmer  and  less  malignant  than 
the  latter.  The  cells  are  larger,  richer  in  cytoplasm,  and  possess  one,  two,  or 
more  large  vesicular  nuclei.  Between  the  specific  cells,  and  dividing  them  more 
or  less  definitely  into  groups  or  alveoli  (alveolar  sarcoma),  there  is  a  delicate  fibril- 
lated  stroma  containing  here  and  there  spindle  and  branching  cells.  The  vessels 
are  generally  thin-walled. 

Spindle-celled  sarcomata  are  among  the  commonest  forms  of  sarcomata.  As  a 
rule  they  are  firmer  than  the  round-celled  form,  and  may  appear  on  section  even 
somewhat  fibrous.  Still,  medullary  forms  occur.  They  are  grayish  or  yellowish 
white  in  color,  somewhat  translucent,  or,  if  vascular,  may  have  a  pinkish  tinge. 
The  cells  lie  for  the  most  part  side  by  side  with  their  long  axes  pointing  in  the  same 


TUMORS  AND  TUMOR  FORMATION. 


335 


general  direction.  Tliey  may  compose  a  large  area  of  the  tumor  after  this  fashion, 
but  are  perhaps  more  commonly  aggregated  into  bundles,  which  run  in  different 
directions,  and,  indeed,  may  to  some  extent  interlace.  Not  infrequently  there  is 
a  definite  relationship  to  the  vessels,  the  bundles  being  grouped  about  them  after 
the  manner  of  a  sheath.  On  teasing  out  a  sarcoma  of  this  kind,  the  spindle  cells 
composing  it  are  found  to  assume  various  types  according  to  the  tumor.  Some  are 
oval  or  oat-shaped,  others  are  short  spindles,  while  still  others  are  provided  with 
long  processes,  so  that  they  approximate  closely  to  the  type  of  the  normal  fibrous- 
tissue  cell. 

The  supporting  stroma  is  often  scanty  or  may  be  scarcely,  if  it  all,  recognizable. 
In  other  cases  it  is  more  abundant  and  presents  a  fibrillar  character.     Those 


Fig.  100. — Lympho-sarcoraa.      Winckel  No.  6,  without  ocular.      (Froni  the  author's  collection.) 

spindle-celled  growths  which  contain  a  relative  abundance  of  stroma  are  usually 
termed  fibro-sarco7nata  (Fig.  101). 

The  mixed-celled  sarcomata  are  composed,  as  the  name  implies,  of  cells  of  sev- 
eral different  types.  It  is  not  uncommon  to  find  sarcomata,  both  of  the  round- 
celled  and  spindle-celled  type,  which  on  closer  inspection  are  found  to  contain  in 
addition  oval,  pyramidal,  prismatic,  stellate,  or  irregularly  shaped  cells.  These 
cells  may  possess  one  or  more  nuclei.  The  most  important  variety  is  the  giant- 
celled  sarcoma. 

This  form  is  one  of  the  most  interesting  to  the  surgeon,  inasmuch  as  it  develops 
in  connection  with  the  bones,  occasionally  in  the  breast,  and  may  reach  a  great 
size.  The  shafts  of  the  long  bones  and  the  alveolar  process  are  the  parts  ordinarily 
attacked.  The  growth  usually  starts  from  the  bone  marrow,  whence  the  term 
sometimes  applied  to  it,  myeloid  sarcoma  (Fig.  102),  and  in  the  course  of  its  growth 


336 


A-AIERICAX   PRACTICE  OF  SURGERY. 


leads  to  great  rarefaction  and  destruction  of  the  bone.  The  denser  outer  shell  is 
thinned  out  and  can  be  found  over  the  surface  of  the  tumor  in  the  form  of  thin 
plates,  that  on  palpation  give  a  curious  sensation  like  thecnimplingof  an  egg  shell 
(egg-shell  crackle) .  In  the  alveolar  process  the  giant-celled  sarcoma  forms  one  va- 
riety of  the  tumor  known  to  surgeons  as  epulis.  It  is  in  this  situation  a  dense, 
firm,  sessile  or  nodular  gi-owth,  tending  to  envelop  the  bone.  It  sometimes  also 
originates  in  the  antrum  of  Highmore.  On  section,  giant-celled  sarcomata  are 
firm,  some^yhat  fibrous,  and  frequently  present  a  brick-red  color  from  parenchy- 
matous hemorrhage.  The  growth  is  one  of  the  least  malignant  forms  of  the  sar- 
comata. 

Microscopically,  there  is  usually  a  good  deal  of  fibrous  tissue  here  and  there,  so 


Fig.  101. — Spindle-celled  Fibro-sarcoma.      Winckel  No.  6,  without  ocular.       (From  the  author's 

collection.) 

that  the  growth  might  be  regarded  as  fibro-sarcoma.  The  specific  cells  are  of 
mixed  variety,  round,  oval,  spindle,  or  irregular,  but  the  characteristic  feature  is 
the  presence  of  relatively  enormous  multinucleated  cells.  Small  patches  of  hem- 
orrhage can  usually  be  made  out  in  various  jmrts  (Fig.  103). 

Sarcomata  of  Definitely  Organoid  Type. — In  this  group  we  place  all  those  sarco- 
mata that,  from  the  peculiar  arrangement  of  their  cells,  remintl  us  somewhat  of 
on  organ.  Thus,  the  cells  may  be  aggregated  into  definite  clusters  or  nests, 
surrounded  by  connective  tissue  {alveolar  sarcoma) ;  others  have  a  tubular  appear- 
ance not  unlike  that  of  a  gland  (tubular  sarcomata) ;  still  others  have  a  stratifietl 
appearance  recalling  the  skin  or  a  lining  membrane.  The  type  is  not  necessarily 
maintained  throughout,  it  should  be  remarked.  Thus  a  certain  tumor  may  at  one 
point  present  an  organoid  structure,  while  in  other  parts  the  appearance  is  rathev 


TUMORS  AND  TUMOR  FORMATION. 


337 


that  of  a  simple,  diffuse,  round-,  spindle-,  or  mixed-celled  sarcoma.  Again,  some 
of  the  new  growths  coming  under  this  category,  consisting  of  large  spindle,  round, 
or  cylindrical  cells  of  epithelioid  appearance,  closely  resemble  the  carcinomata,  for 
which  many  of  them  have  been  mistaken,  particularly  if  they  have  an  alveolar  ar- 


FiG.  102.— Sarcoma  of  the  Lower  End  of  the  Shaft  of  the 
Femur.  The  soft  parts  have  been  removed  by  maceration  to 
show  the  rarefaction  and  expansion  of  the  diaphysis.  (Patho- 
logical Museum  of  McGill  University.) 


rangement.  In  not  a  few  cases  careful  examination  will  show  a  gradual  transition 
from  a  carcinomatoid  to  a  definitely  sarcomatous  appearance  in  the  same  tumor. 
It  is  not  surprising,  therefore,  that  this  class  of  tumors  has  led  to  much  confusion  of 
ideas  and  many  erroneous  deductions.  Standing,  as  regards  their  histological  ap- 
pearance, on  the  border  Ime  between  the  carcinomata  and  the  sarcomata,  they  have 
VOL.  I.— 92 


338  AMERICAN  PRACTICE  OF  SURGERY. 

been  classed  by  different  investigators  in  accordance  with  tlieir  individual  bias  as 
carcinomata  or  as  sarcomata,  while  others  have  boldly  met  the  difficult)'  bj^  ignor- 
ing it  and  calling  them  sarco-carcinomata.  I  would  like  to  emphasize  here  what 
I  have  said  before,  that  it  is  far  more  scientific  to  go  right  to  the  root  of  the  matter 
and  classify  these  according  to  their  origin  and  mode  of  development  rather  than 
on  the  basis  of  mere  superficial  resemblance.  With  careful  study  and  the  use  of 
serial  sections,  the  nature  of  these  puzzling  growths  can  usually  be  made  out, 
though  it  may  be  freely  admitted  that  the  difficulties  cannot  always  be  cleared  up. 

The  chief  forms  which  we  have  to  consider  in  this  connection  are  the  angio- 
sarcomata  and  the  endoiheliomata. 

Under  the  term  angio-sarcoma  we  may  include  any  highly  vascular  sarcoma. 

Two  main  types  may  be  recognized,  though  mixed  forms  and  modifications 
occur,  namely,  the  angiomatous  sarcoma  and  the  periihelial  sarcoma. 


Fig.  103. — Giant-Celled  Sarcoma,  from  tlie  Periosteum.      Winckel  Xo.  0,  mthout  ocular.      (From 
the  author's  collection.) 

The  first-mentioned  may  perhaps  be  regarded,  at  least  in  many  cases,  as  a  cel- 
lular variation  of  the  angioma.  It  consists  of  numerous  blood  capillaries,  be- 
tween which  are  dense  aggregations  of  sarcoma  cells.  The  latterariseas  a  sarcom- 
atous metamorphosis  of  the  connective  tissue  forming  the  supporting  stroma 
found  in  all  angiomata.  Owing  to  the  abundance  of  the  blood  capillaries,  such 
tumors  often  present  a  more  or  less  distinctly  alveolar  arrangement,  which  may 
cause  them  to  be  mistaken  for  carcinomata. 

In  the  perithelial  sarcoma  the  structure  is  still  more  alveolar  in  appearance. 
The  tumor  is  extremely  vascular  and  the  cells  composing  it  are  large,  round, 
spindle-like,  or  cylindrical  in  shape;  they  are  derived  from  the  proliferation 
of  the  connective  tissue  or  perithelium  forming  the  adventitia  of  the  vessels. 


TU-MORS  AND  TUMOR  FORxMATION.  339 

Thus,  larger  or  smaller  cell  clusters  are  found  grouped  around  the  -vessels,  the 
intervening  spaces  being  filled  with  connective  or  mucoid  tissue,  ordinary  sarcoma 
cells,  or  a  finely  granular  debris  (Fig.  104). 

The  perithelial  sarcomata  are  found  in  the  kidne3's,  suprarenals,  prostate, 
thyroid,  parotid,  and  elsewhere.  They  are  extremely  malignant  and  tend  to  in- 
vade the  veins  of  the  neighboring  parts.  Numerous  metastases  may  be  formed. 
When  the  growths  are  superficial  their  extreme  vascularity  is  manifested  by  rhyth- 
mical pulsation  corresponding  to  the  systole  of  the  heart  and  by  a  blowing  murmur 
on  auscultation.  The  blood  can  often  be  squeezed  out  of  the  growth,  only  to 
return  when  the  pressure  is  removed.     Care  should  he  taken  not  to  confuse  such 


Fig.  104. — Perithelial  Angio-sarcoma  of  the  Pituitarj'  Body.      I.eitz  objective  No.  7.      (From  the 
author's    collection.) 

angio-sarcomatous  metastases  with  cirsoid  aneurisms,  arterio-venous  aneurisms,  or 
phlebectasise.  While  on  the  subject  of  angio-sarcomata  I  would  point  out  that,  as 
Flexner's  case  above  referred  to  (p.  327)  proves,  there  is  a  striking  resemblance  be- 
tween the  perithelial  angio-sarcomata  and  certain  tumors  of  the  central  nervous 
system,  regarded  as  being  probably  ependymal  glioma ta,  so  that  further  studj'  of 
brain  tumors  of  this  general  type  may  result  in  considerable  modification  of  our 
present  ideas.  Some  new-growths,  therefore,  at  present  classed  with  the  peri- 
theliomata,  may  eventually  turn  out  to  be  gliomatous  in  origin. 

Under  the  term  endothelioma  we  include  all  tunrors  derived  from  endothelial 
cells,  whether  of  blood-vessels,  lymphatics,  perivascular  lymph  spaces,  or  of  the 
larger  serous  cavities.  The  specific  cells  of  such  tumors  are  romid,  flattened,  or 
cuboidal,  and  bear  a  strong  general  resemblance  to  epithelial  cells.     When  we 


340  AMERICAN  PRACTICE  OF  SURGERY. 

remember  this  and  also  take  into  -account  tlie  fact  that  the  cells  are  not  infre- 
quently arranged  in  alveoli,  bands,  nests,  and  tubules,  it  is  not  surprising  that 
certain  of  the  endotheliomata  should  have  been  mistaken  for  carcinoma ta.  The 
error  is  more  likely  to  occur  if  only  an  isolated  portion  of  the  growth  be  examined ; 
careful  search,  however,  will  often  show  at  some  point  or  other  the  direct  conti- 
nuity of  the  cells  of  the  tumor  with  those  of  some  lining  membrane,  and  reveal 
the  true  nature  of  the  growth. 

The  finer  histological  details  of  endotheliomata  vary  considerably  according 
to  the  character  of  the  structure  from  which  they  take  their  rise.  In  those  origi- 
nating in  the  endotlielium  lining  blood-vessels,  the  specific  tumor  cells  often  show 
a  definite  relationship  to  the  vessels,  which  may  be  so  large,  numerous,  and  tor- 
tuous as  to  give  the  tumor  a  highly  complicated  and  peculiar  structure  {angiosar- 
coma plexiforme).  In  parts  it  may  be  possible  to  detect  the  remains  of  the  vessel 
walls  which  have  been  destroyed  by  the  proliferating  endothelium.  Within  the 
spaces  formed  by  the  more  or  less  imperfectly  formed  tubules  can  sometimes  be 
seen  blood  corpuscles,  suggesting  the  origin  of  the  growth  from  blood-vessels. 
Endotheliomata  derived  from  the  lymphatic  channels  present  a  very  similar  ap- 
pearance. Those  originating  from  the  lining  membranes  of  serous  cavities  and 
tissue  spaces  are  apt  to  have  a  more  alveolar  character,  clumps,  nests,  and  anasto- 
mosing bands  of  epithelioid  cells  being  embedded  in  a  more  or  less  abundant 
stroma  of  connective  tissue.  There  may  be  but  little  ground-substance  of  a 
finely  fibrillar  character,  it  may  form  a  well-defined  stroma  or,  again,  may  be  so 
dense  and  abundant  that  it  gives  a  distinct  scirrhous  character  to  the  growth. 

The  stroma  in  some  cases  exhibits  peculiar  secondary  transformations.  It 
maj'  present  mucinous  degeneration,  forming  one  variety  of  myxo-sarcoma ;  or 
there  may  be  a  hyaline  change  in  the  vessel  walls  and  portions  of  the  stroma,  pro- 
ducing the  curious  growth  known  as  the  sarcomatous  cylindroma. 

Certain  endotheliomata  of  the  dura  are  intensely  fibrous  and  contain  lami- 
nated calcareous  concretions,  similar  to  those  found  normall}'  in  the  pineal  gland 
and  meninges  (brain-sand).  They  have,  therefore,  been  termed  j)sammomata 
(Fig.  105). 

As  will  be  gathered  from  the  above  remarks  there  is  a  striking  similarity  be- 
tween certain  of  the  more  vascular  endotheliomata  and  forms  which  I  have  already 
described  under  the  group  of  angio-sarcomata.  This  has  led  to  some  confusion 
in  the  terminology.  It  would  be  well  if,  with  Waldeyer,  we  should  restrict  the 
term  angiosarcoma  to  tumors  originating  from  the  adventitia  of  blood-vessels, 
and  should  include  under  endothelioma  only  such  tumors  as  originate  from  endo- 
thelial lining  membranes,  whether  vascular  or  not.  It  would  be  still  more  precise 
if  we  were  to  call  tumors  derived  from  the  adventitia  perithelial  angiosarcomata 
or  malignant  peritheliomata.  The  chief  difficulty  with  this  is  that  histologicall}^ 
the  endotheliomata  originating  in  the  periA'ascular  lymph  spaces  are  almost  iden- 
tical with  tlie  p(>rithelial  angio-sarcomata.     In  the  case  of  the  latter  growths  it 


TUMORS  AND  TUMOR  FORMATION 


341 


ought  to  be  possible  to  deiuonstrate  the  direct  continuity  of  the  ceUs  nearest  the 
blood-vessels  with  the  adventitia,  but  this  is  often  a  matter  of  great  difhcult3^ 

Endotheliomata  are  found  usually  in  connection  with  the  serous  sacs,  the 
meninges  of  the  brain  and  cord,  and  connective-tissue  spaces,  occasionally  in  the 
peribronchial  connective  tissue,  the  parotid,  skin,  and  pituitary  body.  Thej' 
form  nodular  or  flattened  sessile  growths,  tending  to  extend  superficially.  The 
denser,  more  fibrous  forms,  especially  those  of  the  meninges,  are  not  particularly 
malignant,  inasmuch  as  they  infiltrate  comparatively  slowly  and  do  not  form  dis- 
tant metastases.     The  softer  cellular  forms  are,  however,  often  highly  malignant. 

The  etiology  is  practically  unknown.  Irritation  appears  to  play  a  part  in 
some  cases.     I  have  met  with  two  instances  in  which  endotheliomata  of  the  dura 


Fig.  105.— Endothelioma  (Psammoma)    of  tlie  Jlrain.      Winckel  No 
the  author's  collection.) 


.3,  without  ocular.      (From 


mater  appeared  to  be  due  to  the  influence  of  a  sharp  spur  of  bone  projecting  from 
the  inner  surface  of  the  calvarium. 

Sarcomata  Presenting  Peculiar  Secondary  Characteristics. — Under  this  heading 
we  will  discuss  the  pigmented  sarcomata  and  certain  forms  presenting  mucoid, 
hyaline,  and  calcareous  transformation. 

The  melanotic  sarcoma  (melanosarcoma;  melanoma;  chromatophoroma)  is  a 
pigmented  sarcoma,  found  usually  in  the  uveal  tract  of  the  eye  or  in  the  skin. 
The  growth  varies  in  size  and  shape  and  is  usually  soft  and  friable.  Its  most 
striking  feature  is  its  color,  which  may  range  from  yellow,  brown,  or  gray  to  the 
most  intense  black.  The  coloration  is  not  always  uniform,  and  some  forms  may 
even  be  speckled.  The  vascularity  may  be  great,  and  in  that  case  it  is  not  unusual 
to  find  areas  of  hemorrhage  in  the  substance  of  the  growth. 


342  .4.MERICAN  PRACTICE  OF  SURGERY. 

^Melanotic  sarcomata  generally  originate  in  structures  that  are  normally  pig- 
mented, though  there  are  occasional  exceptions  to  this  rule.  Those  foimd  in  the 
skin  can  usuallj-  be  traced  to  pigmented  naevi  which  have  taken  on  aberrant 
growth.  These  growths  are  highly  malignant  and  quickl}"  produce  metastases 
in  various  parts  of  the  body,  as  the  liver,  lungs,  intestines,  muscles,  bones,  and 
skm.  In  some  cases  the  secondary  growths  are  exceedingly  numerous,  and  often 
varj-  greatly  in  size,  some  being  almost  microscopical,  others  as  large  as  a  cherry 
or  walnut.  Tlie  primary'  tumor  may  be  quite  small  and  unobtrusive.  Proba- 
bl}'  some  of  the  cases  reported  as  primary  in  the  viscera  are  really  secondarj^,  the 
original  growth  having  been  overlooked. 

Histologically,  there  are  two  t3'pes  of  melanotic  sarcomata,  the  spindle-celled 
and  the  alveolar.  The  pigmented  sarcomata  that  arise  in  the  choroid  of  the  eye 
are  usualh'  of  the  former  variety',  those  occurring  in  the  skin  and  in  nae^i  are 
more  apt  to  be  alveolar. 

The  pigment  is  called  melanin.  Its  nature  is  not  thorough!}-  understood. 
The  old  idea  was  that  it  was  derived  from  the  coloring  matter  of  the  blood,  but 
this  is  imlikel}',  as  it  contains  no  iron.  It  is  known,  moreover,  to  contain  a  consid- 
erable proportion  of  sulphur.  Probably  the  composition  of  the  pigment  differs 
in  different  cases,  and  it  is  altogether  likely  that  it  is  autochthonous  in  nature  and 
produced  b}'  the  metabolism  of  the  chromatophores.  The  pigment  takes  the  form 
of  fine  dust-like  particles,  granules,  or  lumps,  both  withui  the  cells  and  in  the  in- 
terstices of  the  tissue  (Fig.  106).  It  is  highly  refractile  in  appearance  and  of  a  yel- 
lowish, bro\^•nish,  or  black  color.  In  the  alveolar  growths  the  pigment  tends  to 
accumulate  in  the  cells  at  the  periphery  of  the  clusters  and  in  the  neighborhood 
of  the  blood-vessels.  In  the  choroidal  tumors  the  coloring  matter  is  more  imi- 
formly  distributed.  The  amount  may  be  so  great  as  to  mask  the  true  nature  of 
the  specific  tiunor  cells.  In  fact  it  ma}^  so  interfere  with  nutrition  that  liquefac- 
tion and  necrosis  result.  It  is  a  curious  fact  that  the  metastases  often  present  a 
different  degree  of  pigmentation  from  that  presented  by  the  original  growth,  and 
sometimes,  indeed,  they  are  quite  colorless. 

The  exact  status  of  these  timiors  is  still  not  quite  settled.  Unna,  Gilchrist,  and 
others  hold  to  the  epiblastic  nature  of  the  forms  arising  in  connection  ■nath  pig- 
mented n£e^'i,  while  Ribbert  contends  that  the}'  arise  from  pigmented  mesoblastic 
cells  (chromatophores).  On  this  point  depends  the  question  whether  we  are  to 
class  the  melanomata  with  the  carcmomata  or  with  the  sarcomata.  In  the  case 
of  the  eye,  the  chromatophores,  as  Ribbert  points  out,  are  undoubtedly  of  meso- 
blastic origm. 

Another  pigmented  growth  of  a  somewhat  remarkable  nature  is  the  chloroma. 
This  is  a  rare  tumor  which  develops  in  connection  with  periosteimi,  more  espe- 
cially that  of  the  skull,  A'ertebrae,  and  humerus.  Its  peculiar  feature  is  its  color,  a 
green  or  greenish- j'ellow.  This  is  most  mtensewhen  the  tumor  is  freshly  cut,  and 
fades  somewhat  on  exposure  to  the  air. 


TUMORS  AND  TUMOR  FORMATION.  343 

Histologically,  the  chloroma  is  composed  of  round  cells,  resembling  large  and 
small  lymphocytes,  held  together  by  a  delicate  fibrous  reticulum.  The  pigment 
occurs  in  the  form  of  small,  highly  retractile  granules  within  the  cells,  and  is  best 
made  out  in  frozen  sections  or  in  teased-out  material. 

There  is  still  much  doubt  in  regard  to  the  true  nature  of  these  tumors.  Many 
hold  them  to  be  a  form  of  lymph-adenoma  and,  therefore,  related  to  leuktemia  and 
Hodgkin's  disease.  The  coloring  matter  gives  some  of  the  micro-chemical  reac- 
tions of  fat  and  is,  probably,  to  be  classed  as  a  lipochrome. 

Of  the  other  secondary  manifestations  which  sarcomata  may  undergo  we  may 
simply  mention  hyaline  changes  and  the  deposit  of  calcareous  material  in  the 
stroma  {sarcoma  petrificans) 


Fig.  106. — Melanotic  Sarcoma.      Winckel  No.  6,  without  ocular.     (From  the  author's  collection.) 

Sarcomatous  Tumors  of  Mixed  Type. — Under  this  caption  we  can  conveniently 
discuss  those  forms  of  sarcomata  which  represent  cellular  variations  of  the  simple 
benign  tumors. 

In  the  fibrosarcoma  the  connective-tissue  nature  of  the  growth  is  quite  evident. 
As  in  the  fibroma  there  are  cells  of  connective-tissue  type  together  with  a  homo- 
geneous and  fibrillar  intercellular  substance.  In  the  fibro-sarcoma  the  cells  are  more 
numerous,  the  nuclei  plumper,  and  the  fibrillar  substance  less  in  evidence.  As 
may  be  imagined,  it  is  not  easy  in  many  cases,  from  the  histological  appearance 
alone,  to  draw  the  line  between  the  benign  fibroma  and  the  fibro-sarcoma.  It  is 
well  known  to  surgeons  that  a  tumor  which  has  existed  for  a  long  time  and  has 
been  regarded  as  an  innocent  fibroma  may  recur  after  removal,  exhibiting  a  limited 
degree  of  malignancy  (recurrent  fibroma).  The  transition  from  the  fibroma  moUe 
to  the  fibro-sarcoma  is,  in  fact,  almost  imperceptible.     In  another  form  of  fibro- 


344  AMERICAN  PRACTICE  OF  SURGERY. 

sarcoma  the  structure  is  not  so  uniform,  liut  there  are  more  or  less  dense  fibi'ous 
septa  enclosing  spindle-shaped  sarcoma  cells. 

The  niyxo-sarcoma  resembles  the  myxoma,  except  that  the  round  and  stellate 
cells  are  more  numerous,  while  the  nuicoid  and  fibrillar  intercellular  substance  is 
relatively  more  scant}^  The  lipoma  may  also  be  transformed  in  part  mto  myx- 
oma and  subsequently  into  lipo-myxo-sarcoma. 

The  cho)idro-sarcoma  is  a  highly  cellular  tumor  derived  from  the  chondroma. 
It  consists  in  the  main  of  closely  aggregated  round,  o^'al,  or  fusiform  cells  with  rel- 
atively little  cement  substance.  But  the  true  nature  of  the  growth  can  be  made 
out  bj^  recognizing  here  and  there  islets  of  unaltered  cartilage. 

Like  the  lipoma,  the  chondroma  not  infrequentlj'  undergoes  myxomatous  and, 
later,  sarcomatous  change — chondro-myxo-sarcoma. 

The  osteosarcoma  is  a  tumor  consisting  of  bone,  the  medullar}-  spaces  of  which 
contain,  not  marrow,  but  sarcoma  cells. 

The  osteoid  sarcoma  is  similar,  bony  plates  and  spicules  being  formed  which, 
however,  are  not  ossified.  Not  infrequently  subsequent  calcareous  deposit  will 
convert  the  osteoid  sarcoma  into  the  osteo-sarcoma.  These  tumors  are  usually 
found  in  connection  with  the  ]3eriosteum.  The  formation  of  bone  is  probably  due 
to  the  action  of  the  periosteal  osteoblasts,  which  are  in  some  wa}'  stimulated  into 
activity,  and,  possibly,  are  carried  out  into  the  substance  of  the  growth. 

The  supporting  stroma  of  an  angioma  maj'  occasionally  undergo  sarcomatous 
transformation  (angioma  sarcomatodes). 

Myosarcoma,  a  tumor  homologous  with  the  fibro-sarcoma,  myxo-sarcoma, 
and  chondro-sarcoma,  composed  of  undifferentiated  muscle  cells,  is  theoretically 
possible,  but  little  is  known  about  its  actual  occurrence.  The  vast  majority  of 
tumors  described  as  myo-sarcomata  are  either  rhabdo-myomata  or  else  myoniata 
presenting  secondary  sarcomatous  transformation  of  the  intermuscular  fibrous 
supporting  substance.  They  are  more  properly  termed  myoma  sarcomatodes.  Some 
rare  muscle  tumors,  forming  metastases  in  the  internal  viscera,  have  been  described 
in  connection  with  the  uterus,  and  are  believed  by  those  recording  them  to  be 
composed  of  immature  muscle  cells.     These  would  be  the  true  myosarcomata. 

II.  TUMORS  OF  EPITHELIAL  TYPE. 

Under  this  heading  we  would  include  all  tumors  whose  most  notable  feature 
is  that  they  contain  epithelial  elements.  There  is  invariably,  however,  more  or 
less  connective  tissue  present  which  serves  as  a  supporting  stroma  or  matrix, 
so  that  in  a  sense  some  at  least  of  these  growths  may  be  regarded  as  being  of 
mixed  type.  The  proportion  of  connective  tissue  varies  in  different  cases.  In 
some  instances  the  main  mass  of  the  growth  is  composed  of  connective  tissue 
which  is  definitely  proliferating,  the  epithelial  structures  simply  keeping  pace  to 
form  an  external  covering.  Such  tumors  have  more  in  common  with  the  fibro- 
mata and  myxomata  than  with  the  epithelial  growths.     In  others,  the  epithelial 


TUMORS  AND  TUMOR  FORMATION.  345 

elements  are  in  such  excess  that  a  highl}'  celhilar  tumor  is  produced.  A  good 
example  of  the  former  is  the  papilloma;  of  the  latter,  adenoma  and  carcinoma 
may  serve  as  examples.  Strictl}^  speaking,  before  we  should  regard  a  given 
tumor  as  of  epithelial  type,  we  must  be  certain  that  there  is  a  primary  autono- 
mous new  formation  of  epithelial  structures.  It  is  in  man}^  cases,  of  course,  diffi- 
cult to  be  sure  of  this.  Where,  for  example,  epithelial  structures  are  present  in 
small  amount,  it  is  not  impossible  that  they  may  not  be  newly  formed,  but  sim- 
ply entangled  in  the  course  of  the  excessive  proliferation  of  the  fibrous  stroma. 
Therefore,  there  are  not  a  few  tumors  whose  status  is  somewhat  doubtful.  They 
are,  consequently,  discussed  here  largely  as  a  matter  of  convenience. 

As  we  have  seen  above  (p.  329),  papillo7nata  assume  varying  forms  and  are 
of  diverse  etiology.  Many  of  them  have  affinities  with  the  inflammatory  hyper- 
plasias rather  than  with  the  true  neoplasms;  others  are  fibromata,  lipomata,  and 
myxomata  which  have  come  into  special  relationship  with  epithelial  structures. 
Still  others  are  definitely  the  result  of  the  proliferation  of  epithelial  elements. 
The  first  two  classes  have  been  sufficiently  dealt  with  already  (pp.  303  et  seg.), 
but  the  last-mentioned  demands  further  attention.  This  subject  will  be  more  con- 
veniently discussed,  however,  in  connection  with  the  adenomata  and  cystomata. 

Adenomata. 

Adenomata  are  tumors  arising  from  glands  or  gland-like  structures,  the 
structure  of  which  they  more  or  less  perfectly  reproduce.  When  in  the  viscera, 
they  form  circumscribed,  nodular  masses  usually  encapsulated.  On  free  sur- 
faces they  are  apt  to  be  compound,  polypoid,  villous,  or  papillomatous.  As  a 
rule  they  grow  slowly  and  rarely  attain  a  great  size. 

Adenomata  are  moderately  common  and  are  found  more  especially  in  the 
mamma,  kidney,  liver,  suprarenal,  thyroid,  uterus,  and  the  mucous  membrane 
of  the  alimentary  tract;  occasionally,  also,  they  originate  in  the  sudoriparous, 
salivary,  and  lachrymal  glands.  I  have  been  fortunate  enough  to  find  and 
report  a  unique  adenoma  of  the  pancreas  arising  from  an  island  of  Langerhans 
{Journal  of  Medical  Research,  November,  1902).  Structurally,  the  adenomata 
consist  of  an  epithelial  part  and  a  connective-tissue  part.  The  epithelial  cells  usu- 
ally resemble  somewhat  closely  those  of  the  gland  from  which  they  arise,  and  in 
a  general  way  are  arranged  so  as  to  reproduce  the  acini  and  ducts,  but  here  the 
resemblance  usually  ends.  The  regular  structure  of  the  normal  gland  and  the 
relative  proportion  of  its  parts  are  considerably  departed  from.  The  connective 
tissue  forms  a  stroma  supporting  the  glandular  portion  and  in  different  cases 
varies  greatly  in  amount. 

It  is  usual  to  divide  the  adenomata  into  two  classes,  according  to  their  histo- 
logical appearance,  namely,  the  tubular  adenomata  and  the  alveolar  adenomata, 
to  which  may  possibly  be  added  a  third,  the  papuliferous  adenomata.  In  the 
first-mentioned  variety  the  epithelial  cells  are  in  large  measure  arranged  after 


346  AMERICAN  PRACTICE  OF  SURGERY. 

the  fashion  of  tubules  or  ckicts  possessing  definite  lumina.  The  alveolar  or 
acinous  adenoma  reminds  one  of  the  normal  acini  of  the  gland,  save  that  they 
are  much  more  numerous,  and  are  apt  to  be  larger  and  more  highly  convoluted. 
In  the  case  of  the  papuliferous  form,  the  connective  tissue  forming  the  walls  of  the 
acini  or  ducts  proliferates  actively  and,  pushing  the  epithelial  cells  before  it, 
encroaches  upon  the  cavities,  which  often  become  dilated,  in  the  form  of  polypoid 
or  papillary  protuberances. 

Adenomata  are  formed,  probably,  much  in  the  same  way  as  glandular  struc- 
tures are  normally  produced,  namely,  by  the  proliferation  of  the  epithelium, 
which  penetrates  the  connective-tissue  stroma  and  assumes  the  form  of  acini  and 
tubules.  These  structures  are,  however,  produced  in  excess,  and  in  some  in- 
stances there  is  evidence  that  the  stroma  is  not  entirely  passive,  but  partici- 
pates in  the  overgrowth  also. 

Certain  of  the  adenomata  are  of  considerable  practical  importance  to  the 
surgeon.  Of  these  may  be  mentioned  the  adenomata  of  the  manmia,  kidney, 
suprarenal,  thyroid,  prostate,  testis,  and  uterus. 


Fig.  107. — Fibro-adenoma  of  the  Mamma,  of  the  Acinous  Type.      Winckel  No.  3,  without  ocular. 
(From  the  author's  collection.) 

The  adenomata  of  the  breast  take  the  form  of  notlular  masses,  the  size  of  a 
hazelnut  or  larger,  which  are  movable,  elastic,  and  moderately  firm.  On  section 
they  are  lobulated,  and  the  lumina  of  the  dilated  gland  tubules  and  acini  can  be 
recognized  on  the  cut  surface.  Occasionally,  areas  of  softening  and  cystic  degen- 
eration can  be  detected.  They  are  of  slow  growth,  do  not  cause  retraction  of  the 
nipple,  do  not  involve  the  axillary  nodes,  and  do  not  recur  after  removal. 

Histologically,  several  varieties  may  be  recognized.  Certain  of  the  fibromata 
of  the  breast,  above  described,  contain  a  more  or  less  notable  amount  of  glandular 


TUMORS  AND  TUMOR  FORMATION. 


347 


structure.  This  may  in  some  cases  be  an  accidental  admixture,  but  not  infre- 
quently with  the  overgrowth  of  the  fibrous  tissue  there  is  undoubted  new  forma- 
tion of  glandular  acini.  Such  tumors  are  often  termed  adeno-f-bromata  and 
fibro-adenomata,  according  to  the  relative  proportions  of  the  two  elements  present 
(Fig.  107).  Pure  adenomata  of  the  mamma  are  somewhat  rare.  In  some 
instances  the  newly  formed  glandular  tissue  results  in  the  production  of  new 
terminal  acini,  associated  together  in  groups,  and  lined  with  cubical  epithelium, 
resembling  somewhat  closely  the  structure  of  the  normal  functioning  gland.  In 
others  the  growth  is  erratic,  presenting  irregular  tubules  lined  with  cubical  and 
cylindrical  cells.  The  various  tubules  and  acini  are  bounded  externally  by  a 
doubly  refractile  basement  membrane.  The  recognition  of  this  structure  is  im- 
portant, for  so  long  as  it  remains  intact  the  growth  is  benign.  Should  the  gland- 
ular elements  proliferate  irregularly  and  appear  outside  the  basement  membrane 
the  tumor  would  be  called  a  carcinoma.  Many  carcinomata  of  the  breast  origi- 
nate in  a  simple  adenoma  and  are  hence  called  adeno-carcinomata,  though  there 
is  no  doubt  that  some  arise  directly  from  the  glandular  epithelium. 


Fig.  108. — Foetal  Adenoma  of  the  Thyroid.      Winckel  No.  3,  without  ocular.      (From  the  author's 

collection.) 


Adenomata  of  the  kidney  are  well-defined,  rather  soft,  growths,  of  whitish  col- 
or, which  may  be  microscopic  in  size  or  may  attain  that  of  a  walnut.  Histolog- 
ically, they  are  tubular,  acinous,  or  papuliferous.  The  epithelium  resembles 
more  or  less  closely  that  of  the  secreting  tubules.  Some  of  the  renal  adenomata, 
however,  have  been  shown  to  originate  in  misplaced  suprarenal  "rests"  (benign 
hypernephromata).     The  adenomata  of  the  kidney  may  become  malignant. 

Glandular  benign  tumors  of  the  thyroid  are  of  three  types,  simple,  foetal,  and 


348 


AMERICAN  PRACTICE  OF  SURGERY. 


papuliferous  adenomata.  The  simple  adenoma  consists  of  follicles  filled  -with  col- 
loid, resembling  those  of  the  normal  thyroid.  The  epithelium  lining  the  follicles 
is  cuboidal  or  somewhat  flattened.  In  the  supporting  stroma  can  be  seen  here 
and  there  islets  of  similar  cells,  resembling  embryonic  thyroidal  structure.  The 
growth  may  be  diffuse  (colloid  struma)  or  localized  and  encapsulated.  In  some 
cases  the  colloid  increases  in  amount,  the  follicles  enlarge,  the  intervening  walls 
atrophy  and  rupture,  and  thus  cysts  filled  with  colloid  result  (cystic  goitre). 
Simple  adenomata  are  usuall}'  single,  but  ma}^  be  multiple. 

The  foetal  adenomata  resemble  in  structure  the  foetal  thyroid.     The  cells  are 
arranged  in  solid  columns  and  clusters,  in  Avhich  occasionally  minute  lumina-may 


Fig.  109. — Adenomatous  Enlargement  of  the  Prostate.      An  "  amyloid  body  "  may  be  seen  at  tlic  lower 
part  of  the  section.      Winckel  No.  3,  without  ocular.      (I<>om  the  author's  collection.) 

be  discovered,  hut  colloid  is  not  present.  The  tumor  is  usually  encapsulated,  is 
whitish  or  reddish  in  color,  and  of  soft  consistence.  As  a  rule  it  is  quite  vascular. 
(Fig.  lOS.) 

The  papilliferous  adenomata  usually  originate  in  the  walls  of  old  cysts,  but 
very  rarely  they  are  true  paiiilliferous  adeno-cystomata,  comparable  to  those  of 
the  ovary. 

Adenomata  of  the  suprarenal  capsule  are  quite  common,  but  rarely  attain  any 
size.  It  is  interesting  that  misplaced  suprarenal  tissue  may  give  rise  to  adeno- 
mata in  unlikely  situations  sucli  as  the  kidney,  peritoneum,  and  broad  ligament. 

The  enlargement  of  the  prostate  that  so  often  occurs  in  old  age  is  due  to  an 
overgrowth  of  the  glandular  portion,  the  fibro-muscular  stroma,  or  both.  When 
the  glandular  elements  are  increased  the  prostate  is  enlarged,  spongy,  and  moder- 
ately soft,  and  on  pressure  a  fluid  rich  in  cells  can  be  expressed.     The  overgrowth 


TUMORS  AND  TUMOR  FORMATION.  349 

is  usually  generalized,  but  nodular  masses  may  be  formed.  Microscopically,  the 
acini  of  the  gland  are  increased  in  numbers,  are  enlarged,  tortuous,  and  often  di- 
lated. They  frequently  contain  concretions  (Fig.  109).  There  issome  doubt  as  to 
whether  the  condition  should  be  regarded  as  a  simple  glandular  hyperplasia  or  a 
true  tumor  formation.  The  importance  of  the  condition  lies  in  the  fact  that  the 
overgrowth  leads  to  encroachment  upon  the  urethra,  which  it  obstructs.  This  is 
particularly  apt  to  be  the  case  when  the  so-called  middle  lobe  is  enlarged.  As  a 
consequence  the  bladder  becomes  hypertrophied,  later  dilated,  and  at  times  in- 
flamed (Fig.  94).  Even  the  ureters,  the  pelvis  of  the  kidneys,  and  the  kidney 
proper  may  become  dilated  from  the  excessive  pressure. 

Adenoma  of  the  testis  originates  in  the  seminiferous  tubules  and  may  be  solid 
or  cystic.  When  present,  the  cysts  are  filled  with  a  clear  mucoid  material  {cyst- 
adenoma  mucosum)  or  with  a  cheesy  detritus  (cystadenoma  atheromatosum) .  In 
the  latter  variety  the  cysts  are  lined  with  a  thick,  somewhat  keratinized  epithe- 
lium. Cartilage  and  muscle  fibres  are  not  infrequently  present,  suggesting  the 
teratoid  nature  of  the  growth.  In  a  few  cases  there  may  be  a  sarcomatous 
transformation  of  the  stroma  {adeno-sarcoma  or  cystadeno-sarcoma  testis). 

In  determining  the  nature  of  a  glandular  overgrowth  occurring  in  connection 
with  the  lining  membrane  of  the  uterus  considerable  difficulty  is  encountered.  In 
the  uterus  the  mucosa  lies  directly  upon  the  muscular  wall  without  the  interven- 
tion of  a  submucosa.  The  uterine  glands  also  occasionally  penetrate  into  the 
muscle.  In  inflammation,  as  for  example  in  endometritis  proliferans,  the  tubules 
are  enlarged,  often  dilated,  and  increased  in  numbers,  sometimes  forming  inter- 
communicating spaces.  The  resemblance  to  a  tumor  is  close.  Moreover,  round- 
celled  infiltration  which  might  in  other  cases  be  of  diagnostic  value  is  present  in 
both.  In  making  the  differentiation  between  endometritis  and  adenoma  on  the 
one  hand,  and  between  adenoma  and  adeno-carcinoma  on  the  other,  regard  must 
be  had  to  the  extent  of  the  glandular  proliferation.  In  many  cases,  however,  we 
must  be  in  doubt.  Some  authors  describe  an  adenoma  of  the  uterus  consisting  of 
numerous  enlarged,  dilated,  and  uitercommunicating  tubules  held  together  by  a 
somewhat  scantj'  stroma.  The  tubules  are  lined  by  a  single  layer  of  irregular, 
compressed-looking  cylindrical  cells,  often  ciliated  and  showing  mitoses.  The 
tumor  is  apt  to  infiltrate  and  forms  a  connecting  link  with  the  adeno-carcinomata 
(adenoma  uteri  malignum). 

From  what  has  just  been  said  on  the  subject  of  adenomata  of  the  prostate  and 
uterus,  it  may  be  inferred  that  there  is  a  close  resemblance  between  simple  gland- 
ular hyperplasia  and  adenomatous  new  formations,  and  this  is,  indeed,  the  fact. 
Structurally,  the  appearances  in  both  are  practically  identical,  any  difference  be- 
ing merely  that  of  degree.  If  we  take,  for  example,  the  mucous  membrane  of  the 
stomach  and  intestines,  it  is  not  unusual  to  find,  in  the  neighborhood  of  chronic 
inflammatory  patches  and  especially  ulcers,  that  the  tissues  are  undergoing 
marked  hyperplasia.    This  must  be  regarded  as  an  attempt  at  regeneration,  but 


350  AMERICAN  PRACTICE  OF  SURGERY. 

while  in  some  cases  it  leads  to  the  repair  of  the  injury  by  the  formation  of  normal 
mucous  membrane,  it  not  infrequently  occurs  in  excess  and  produces  tumor-like 
polypoid  outgrowths.  Histologically,  such  structures  conform  in  appearance  to 
tubular  glands,  but  deviate  somewhat  from  the  normal  in  that  the  glandular  ele- 
ments are  more  irregularly  disposed  and  branched.  In  a  certain  sense  there  is  an 
atypical  glandular  formation.  The  overgrowth  may  also  be  so  active  that  the 
glands  are  dilated  and  we  get  a  kind  of  papillary  excrescence.  Such  formations 
occur  also  in  the  absence  of  any  pre-existing  inflammation,  and  in  these  cases  must 
be  regarded  as  true  hypertrophies.  Here  we  begin  to  enter  the  region  of  the 
adenomata.  Irritation  of  some  kind  would  seem  to  be  of  some  importance  in  the 
etiology  of  these  growths.  The  fact  that  they  are  sometimes  found  at  birth  sug- 
gests in  some  cases  the  influence  of  developmental  anomalies.  An  interesting 
confirmation  of  this  is  found  in  those  adenomata  which  are  traceable  to  misplaced 
portions  of  the  suprarenals  and  thyroid  gland.  These  can  hardly  be  attributed 
to  anything  but  the  proliferation  of  cells  or  remnants  of  organs  which  have  in  the 
course  of  embryonic  development  been  dislocated  from  their  natural  environ- 
ment. 

The  adenomata  are  usually  considered  to  be  benign  tumors.  They  may,  how- 
ever, take  on  atypical  and  aberrant  growth,  and  may,  therefore,  pass  on  into  car- 
cinoma. There  would  appear  to  be  a  gradual  transition  of  forms  between  the 
simple  adenoma  and  the  frankly  malignant  adeno-carcinoma.  This,  again,  has 
led  to  some  confusion  of  terms  and  ideas.  There  are  certain  tumors,  that  histo- 
logically must  be  classed  with  the  simple  adenomata,  which  on  occasion  are  com- 
petent to  produce  distant  metastases.  The  secondary  growths  in  their  turn  pre- 
sent the  structure  of  a  plain  adenoma.  In  a  sense  they  are  comparable  to  the 
chondroma,  which  acts  occasionally  in  a  manner  sunilar.  Such  are  some  of  the 
adenomata  of  the  thyroid,  the  intestinal  tract,  the  ovary,  and  the  uterus.  It 
is  perhaps  a  matter  of  taste  whether  we  term  these,  with  certain  authors, 
adenoma  malignum  or  carcinomatoswn ,  or  carcinoma  aclenomatosum. 

CYSTOMATA. 

Closely  allied  on  the  one  hand  to  the  fibromata  and  on  the  other  to  the  adeno- 
mata are  certain  forms  of  cystic  growths  known  as  epithelial  or  proliferation  cys- 
tomata. 

It  would  be  well  here  to  keep  constantly  in  mind  the  distinction  that  exists 
between  a  cyst  and  a  cystoma.  In  a  broad  way  a  cyst  may  be  defined  as  a  patho- 
logical cavity  containing  fluid  or  semifluid  material.  The  term  does  not  connote 
any  new  formation  of  tissue.  As  examples  we  may  cite  the  degenerative  cysts 
that  often  are  met  with  in  tumors  and  inflammatory  infiltrations,  the  result  of 
necrosis  and  liquefaction  of  the  substance,  retention  cysts,  the  developmental 
cysts  occurring  in  connection  with  the  embryonic  fissures,  and  parasitic  cysts.     A 


TUMORS  AND  TUMOR  FORMATION.  351 

cystoma  is  a  true  tumor,  resulting  from  the  proliferation  of  a  matrix  that  tends  to 
form  cavities.     It  is  possessed  of  powers  of  independent  growth. 

The  true  cystomata  generally  arise  in  structures  that  contain  epithelium. 
When  occurring  elsewhere  they  must  be  derived  from  "cell  rests"  or  misplaced 
embryonic  tissue,  and  should,  therefore,  be  classed  with  the  teratomata  {q.  v.). 
The  cavities  in  a  cystoma  are  single,  multiple,  or  multiloculated,  and  are  lined 
by  epithelial  cells.  The  material  contained  within  the  cysts  is  fluid  or  semifluid, 
presumably  the  result  of  the  secretory  activity  of  the  lining  cells,  or  in  part  a  tran- 
sudation from  the  lymph-  and  blood-vessels.  The  fluid  often,  also,  contains 
cholesterin,  fatt}^  and  caseous  matter,  blood,  pigment,  and  cell  detritus. 

With  regard  to  the  gross  structure  these  tumors  may  be  largely  cysts  or,  again, 
they  may  be  partly  solid  and  partly  cystic. 

Histogenetically,  they  are  found  to  have  aflfinities  with  the  adenomata  and 
the  papillomata. 

Favorite  sites  for  proliferation  cysts  are  the  thyroid,  breast,  ovary,  kidney, 
liver,  broad  ligament,  wall  of  the  uterus,  and  vagina. 

The  first  method  by  which  cystic  tumors  may  develop  from  the  adenoma  is 
well  illustrated  in  the  case  of  the  thyroid  gland.  Here,  in  the  lobules  of  the  gland 
new  acini  containing  colloid  are  formed,  constituting  an  adenoma  or  colloid 
struma.  The  colloidal  secretion  gradually  increases  until  the  walls  of  the  acini 
become  greatly  distended  and  finally  rupture,  many  of  them  thus  becoming 
confluent.  In  this  way  there  are  sometimes  formed  cystic  cavities  of  consider- 
able size  containing  colloid  and  often  blood.  This  might  be  termed  the  gland- 
ular type  of  cystoma. 

The  second  type  is  the  papilliferoiis  cystoma.  A  good  example  of  this  is  to  be 
found  in  the  intracanalicular  papilloma  of  the  mamma.  This  originates  in  a  fibro- 
adenoma of  the  organ.  Such  tumors  usually  contain  at  some  part  or  other  some- 
what dilated  ducts  and  acini  (tubular  adenoma).  The  interstitial  stroma  of  con- 
nective or  mucoid  tissue  proliferates,  forming  papillary  processes  that  project  into 
the  glandular  spaces,  gradually  distending  them.  These  outgrowths  are  covered 
with  epithelium  and  may  become  highly  complicated  and  exuberant  in  their 
career,  in  some  cases  even  extending  through  the  ducts  of  the  hippie  and  appear- 
ing externally. 

The  ovarian  cystomata  are,  too,  of  great  practical  importance,  being  among 
the  most  common  neoplasms  affecting  these  organs.  They  are  unilateral  or  bilat- 
eral, unilocular  or  multilocular.  They  produce  symptoms  largely  by  their  size 
and  weight,  but  one  variety,  the  papillary  cystadenoma,  exhibits  a  marked  tend- 
ency to  become  malignant. 

The  most  frecjuent  variety  is  the  simple  cystoma.  This  is  commonly  unilat- 
eral and  is  composed  of  one  cyst  of  relatively  large  size,  together  with  sev- 
eral smaller  subsidiary  cysts.  The  cyst  wall  is  tough,  thin,  and  translucent,  and 
the  cavities  are  filled  with  a  viscid,  mucinous  fluid,  either  clear  and  colorless  or 


352  AMERICAN  PRACTICE  OF  SURGERY. 

mixed  with  cell  detritus  and  blood.  The  cyst  Avail  is  composed  of  two  layers  of 
fibrous  tissue,  the  outer  dense,  the  inner  vascular  and  more  cellular.  The  lining 
membrane  of  the  cavities  is  usually  composed  of  a  single  layer  of  high  cylindrical 
cells,  but,  in  the  larger  cysts,  of  short  columnar,  cuboidal,  or  even  flattened  cells. 
The  lining  epithelium  often  extends  outward  into  the  wall  of  the  c}^sts,  forming 
simple  or  compound  gland  tubules.  It  is  rare  for  the  epithelium  to  be  stratified. 
Occasionally  the  epithelium  is  ciliated. 

A  second,  but  rare  form  is  a  pedunculated  multilocular  cyst  of  moderate  size, 
usually  unilateral,  lined  with  cylindrical  epithelium.  The  contents  of  the  cysts 
are  thin,  more  serous  than  in  the  first  form,  light  yellow  or  greenish  in  color,  and 
rich  in  albumin. 

The  most  important  type,  however,  is  the  papillary  cystoma,  or  cystadenoma 
papilliferum.  This  is  a  multilocular  or,  occasionally,  unilocular  cyst,  which  is  apt 
to  be  bilateral.  The  cysts  are  usually  smaller  than  those  of  the  simple  cystade- 
noma and  are  more  or  less  filled  with  warty,  villous,  or  tree-like  formations  of  con- 
nective tissue  covered  with  ciliated  epithelium  (Fig.  110).  In  a  few  cases  cilia  are 
absent  or  are  present  only  on  the  papillte.  The  growth  extends  between  the  lay- 
ers of  the  broad  ligament  or  forms  a  pedunculated  mass  springing  from  the  sur- 
face of  the  ovary.  The  fluid  contained  within  the  cysts  is  thin,  watery,  often 
dark  colored,  and  more  serous  than  that  of  the  simple  cystadenoma.  Not  infre- 
quently the  cauliflower-like  excrescences  appear  externally,  either  because  the 
outer  wall  of  certain  of  the  cavities  has  given  way  or  because  of  an  actual  inva- 
sion of  the  wall  by  the  new  growth. 

This  form  of  cystadenoma  has  a  great  tendency  toward  excessive  and  inde- 
pendent growth.  According  to  Pfannenstiel  about  one-half  the  cases  in  time  be- 
come malignant.  In  rare  cases  the  tumor  spreads  along  the  peritoneum,  forming 
local  metastases  that  reproduce  the  cystic  and  adenomatous  character  of  the  pri- 
mary tumor. 

The  pathogeny  of  ovarian  cystadenomata  is  not  at  all  clear.  As  Orth  has 
pointed  out,  all  sorts  of  transitional  forms  exist  between  the  simple  and  the  papil- 
lary varieties.  This,  together  AA'ith  the  fact  that  in  all  varieties  the  cysts  may 
be  lined  with  ciliated  epithelium,  suggests  that  the  ovarian  cystadenomata 
have  a  common  origin.  This  is  by  no  means  necessarily  so,  however,  for  it  has 
been  shown  that  under  certahi  circumstances  non-ciliated  epithelium  may  acquire 
cilia.  Theoretically,  ovarian  cystadenomata  may  arise  from  the  epithelium  of 
the  follicles,  from  the  superficial  germinal  epithelium,  from  certain  tubules  of  the 
paroophoron  (Waldeyer),  from  displaced  "rests"  of  the  ciliated  tubal  epithelium 
(Kassmann),  or  from  remains  of  the  Wolffian  body  (Koelliker).  The  develop- 
mental origin  of  many  of  them  is  supported  by  several  observations.  Cystadeno- 
mata are  usually  met  with  during  the  period  of  sexual  activity  and,  often,  in  both 
ovaries.  Cases  have  been  reported  where  sisters  or  mother  and  daughter  have 
been  affected,  suggesting  a  hereditary  peculiarity.     Again,  it  is  not  uncommon  to 


TUMORS  AND  TUIVIOR  FORMATION. 


353 


find  the  combination  of  a  cystadenoma  and  a  dermoid.  Autliorities  are  not 
agreed  wliether  to  assign  the  same  mode  of  origin  to  the  simple  cystadenomata 
and  the  papiUiferous  forms.  Orth  is  inclined  to  attribute  the  majority  of  them  to 
the  same  precursor,  the  germinal  epithelium. 

The  cystomata  of  the  kidney  rarely  attain  a  large  size.  The  congenital  cystic 
kidney  is  in  some  cases  probably  to  be  regarded  as  a  true  tumor  or  cystadenoma. 
Certain  of  the  smaller  ones  may  be  traced  to  misplaced  suprarenal  "rests." 
The  alveolar,  tubular,  and  papillary  adenomata  of  the  kidney  occasionally  give 
rise  to  cystic  growths  not  unlike  those  of  the  ovary  in  outward  appearance. 

Multiple  cysts  of  congenital  origin  have  been  foimd  in  the  liver.  The  condi- 
tion is  often  associated  with  congenital  cysts  of  the  kidney.  Little  is  known  posi- 
tively about  them.     They  are  probably  to  be  regarded  as  true  cystomata,  com- 


FiG.  110. — PapiUiferous  Cystoma    of  the  Ovary.     Leitz  objective  No.  3,  without  ocular.      (From  the 
author's  collection.) 

parable  in  most  respects  to  those  of  the  kidney.  Some  of  them  may  possibly 
start  from  suprarenal  "  rests  "  in  the  liver,  inasmuch  as  suprarenal  tissue  has  occa- 
sionally been  found  there. 

Carcixomata  (Atypical  Epi-,  Meso-,  and  Hypo-lepidomata). 

Just  as  we  have  malignant  new  growths  that  are  cellular  variations  of  con- 
nective tissue  and  are  known  as  sarcomata,  so  we  can  recognize  malignant  neo- 
plasms of  epithelial  origin — the  carcinomata.  We  may  pursue  the  parallel  fur- 
ther. As  we  get  sarcomatous  transformation  of  tumors  derived  from  fibrous 
tissue  and  its  congeners,  as  for  example  in  fibromata,  myxomata,  chondromata, 
osteomata,  so  we  may  have  carcinomatous  metamorphosis  of  the  benign  epithelial 
growths — the  papilloma,  adenoma,  and  cystoma. 

VOL.    T  _93 


354  AMERICAN  PRACTICE  OF  SURGERY. 

A  carcinoma  may  be  defined  as  a  malignant  tumor  arising  from  epithelium.  It 
possesses  a  remarkable  tendency  to  local  infiltration,  sooner  or  later  undergoes 
partial  necrosis,  and  commonly  produces  secondary  new  growths  in  distant  parts 
(metastasis).  Carcinomata  arise  wherever  epithelium  is  found,  from  the  super- 
ficial epithelium  of  the  skin,  from  the  epithelium  lining  the  alimentary  tract  and 
lungs,  and  from  the  invaginations  of  epithelium  constituting  the  secreting  glands. 
Carcinomata  occasionally,  also,  manifest  themselves  in  structures  where  epithe- 
lium is  not  normally  present,  as,  for  instance,  deep  down  in  the  neck  (in  con- 
nection with  the  branchial  clefts)  and  in  the  walls  of  dermoid  cysts.  Such  an 
occurrence  does  not  invalidate  the  general  rule,  for  in  such  cases  the  tumorn  orig- 
inate from  embryonic  epithelium  which  has  become  displaced  and  separated  from 
its  proper  environment  in  the  course  of  development.  From  the  standpoint  of 
embryology  the  epithelium  from  which  carcinomata  are  developed  may  belong  to 
any  of  the  three  primitive  cell  aggregations — ectoderm,  entoderm,  or  mesoblast. 

Histologically,  carcinomata  resemble  the  epithelial  or  fibro-epithelial  struct- 
ures from  which  they  spring,  with  one  important  difference  to  be  referred  to  anon. 
We  find  masses  of  epithelial  cells  of  varying  size  and  shape  enclosed  in  spaces  or 
alveoli,  and  supported  by  a  connective-tissue  stroma  carrying  the  blood-vessels 
for  the  support  of  the  tissues.  The  connective  tissue  and  the  blood-vessels  never 
penetrate  the  epithelial-cell  masses. 

We  can  best  understand,  perhaps,  the  nature  of  carcinoma  and  the  sequence  of 
events  that  give  rise  to  it  if  we  consider  for  a  moment  the  normal  proliferation  of 
epithelial  structures.  Epithelial  tissues  are  among  the  most  active  in  the  bodj^ 
Owing  to  the  demands  of  function  and  their  exposed  position  they  are  subjected  to 
a  great  amount  of  wear  and  tear.  This  is  quickly  made  good.  The  reparative 
powers  of  epithelial  cells,  however,  are  not  only  sufficient  for  these  lesser  calls,  but 
are  competent  to  replace  extensive  losses  of  substance.  Moreover,  under  certain 
circumstances,  as,  for  example,  under  the  influence  of  irritation,  large  masses  of 
tissue,  composed  principally  of  epithelial  elements,  can  be  produced.  In  addition 
to  the  proliferation  of  the  epithelial  cells  in  such  cases  there  is  a  new  formation  of 
connective  tissue,  which  acts  as  a  supporting  stroma  and  carries  the  blood-vessels. 
Such  a  structure  repeats  somewhat  closely  the  appearances  of  the  original  tissue 
from  which  it  sprang  and  is,  therefore,  called  typical.  Of  this  nature  are  certain 
papillomatous  and  polypoid  outgrowths,  warts,  and  condylomata,  before  referred 
to,  that  stand  in  an  intermediate  position  between  the  simple  inflammatory  hy- 
perplasia! and  the  true  tumors.  But  we  may  go  further  than  this.  If  we  take, 
for  instance,  a  chronic  ulcer  of  the  skin  and  subcutaneous  tissues,  it  is  not  unusu- 
al to  find  marked  evidences  of  proliferation  of  the  epithelial  cells  of  the  cutis  at 
the  periphery  of  the  lesion.  The  epithelium  is  thickened  and  tends  to  penetrate 
deeply  into  the  loose  connective  tissue  resulting  from  the  inflammatory  action. 
In  fact,  the  ordinary  histological  features  of  the  epithelioma  or  epidermal  carci- 
noma are  simulated  with  remarkable  accuracy.     Such  a  growth  must,  therefore,  be 


TUMORS  AND  TUMOR  FORMATION.  355 

termed  atypical.  There  is,  however,  this  important  fact  to  be  noted :  the  down- 
ward extension  of  the  superficial  epithelial  cells  only  extends  as  far  as  the  confines  of 
the  altered  connective  tissue,  and  ceases  so  soon  as  the  source  of  irritation  is  removed. 
In  other  words,  the  new  growth  is  not  autonomous.  In  the  carcinomata,  on  the 
other  hand,  while  the  proHferating  epithelial  cells  retain  a  somewhat  close  resem- 
blance to  those  from  which  they  are  derived  and  with  which  they  are  in  anatom- 
ical continuity,  they  grow  wildly  and  without  regard  to  the  neighboring  struct- 
ures. The  orderly  arrangement  of  the  original  tissues  from  which  they  spring 
is  departed  from.  Structurally  speaking,  there  is  no  normal  prototype  of  the 
carcinoma.  This,  then,  is  the  crucial  point  in  the  differentiation  of  carcinomata 
from  other  forms  of  epithelial-cell  proliferation:  the  overgrowth  is  not  only  atypical 
but  it  is  aberrant.  Inasmuch  as  the  proliferation  appears  to  be  the  result  of  forces 
inherent  in  the  epithelial  cells  themselves,  the  carcinomata,  like  other  tumors,  are 
autonomous  formations.  To  illustrate.  Let  us  take  the  case  of  carcinomatous 
transformation  of  the  adenoma  of  the  breast,  an  occurrence  that  is  by  no  means 
uncommon.  In  the  adenoma  we  have  a  more  or  less  abundant  new  formation  of 
acini,  ducts,  and  tubules,  closely  resembling  those  of  the  normal  functioning  gland, 
enclosed  in  an  orderly  fashion  within  a  basement  membrane.  The  glandular 
nature  of  the  growth  is  quite  evident.  The  epithelial  cells  of  such  an  adenoma 
may  at  times  take  on  excessive  action.  They  proliferate  more  rapidly,  are  heaped 
up  in  places,  and  finally  break  the  bounds  of  the  limiting  membrane  and  appear 
in  the  intervening  fibrous  stroma.  Here  they  form  rounded,  oval,  elongated,  or 
irregular  solid  clusters,  in  which  the  arrangement  into  acini  and  ducts  can  no 
longer  be  traced.  These  masses  are,  however,  in  direct  continuity  with  the  epi- 
thelial elements  of  the  original  tumor.  Such  an  atypical  and  disorderly  growth  of 
the  epithelial  cells  constitutes  a  carcinoma.  In  a  similar  fashion  papillomata, 
especially  those  of  an  adenomatous  character,  such  as  the  papillomata  of  the 
bladder  and  rectum,  and  certain  cystomata,  may  take  on  malignant  action. 

In  the  cases  just  cited,  the  carcinoma  originates  as  a  cellular  variation  of  a 
tumor  of  organoid  type.  But  this  is  not  the  only  way.  Carcinoma  may  originate 
directly  from  epithelium  without  going  through  an  intermediate  organoid  stage. 
This  occurs,  for  instance,  in  the  skin  and  mucous  surfaces.  In  the  development 
of  squamous-celled  carcinoma  or  epithelioma  of  the  skin,  the  part  is  first  enlarged 
owing  to  the  simple  hyperplasia  of  the  Malpighian  layers,  the  follicles,  and  glands. 
But  soon  the  aberrant  character  of  the  growth  becomes  evident.  The  proliferating 
cells  begin  to  penetrate  the  subjacent  fatty  and  connective  tissue  as  frnger-like 
processes  and  strands  of  cells,  which  in  parts  coalesce,  forming  a  sort  of  network. 
The  normal  relationships  of  the  various  tissues  entering  into  the  part  are  quickly 
obliterated,  as  the  growth  becomes  exuberant  and  erratic  (Fig.  111).  In  a  sim- 
ilar way,  carcinomata  of  the  mucous  membranes,  as  of  the  stomach  and  bowels, 
begin  with  hyperplasia  of  the  glandular  elements,  the  cells  of  which  increase  in 
size  and  numbers,  penetrate  the  basement  membranes,  burst  through  the  muscu- 


356 


AMERICAN  PRACTICE  OF  SURGERY. 


laris  mucosffi,  and  eventualh-  appear  in  the  muscular  wall.  The  term  adeno-car- 
cinoma,  so  often  employed,  refers  to  a  carcinoma  that  reproduces  the  glandular 
tj^e  in  a  recognizable  degree.  The  large  majorit}'  of  carcinomata  are  adeno-car- 
cinomata. 

Having  considered  the  manner  in  which  carcinomata  originate,  we  may  prop- 
erly inquire  into  their  mode  of  growth.  This  depends  in  large  measure  on  the 
nature  of  the  supporting  stroma  of  the  part  involved.  In  the  case  of  connective 
tissue  we  haA-e  a  mesh  work  of  fibres,  between  which  lie  the  cells  proper.  The  spaces 
form  an  interconimunicating  system  and  are  the  radicles  of  the  lymphatic  chan- 
nels. Now,  if  a  mass  of  epithelial  cells  begins  to  proliferate,  and  does  not  extend 
to  the  surface  after  the  manner  of  a  typical  growth,  it  extends  downward  and 
at  once  enters  this  system  of  tissue  spaces,  where  it  continues  to  grow. 


J.:/- 


mr-^^t^-^P^ 


n'-*^'" mT-     '■ 


Fig.  111. — Epithelioma.     Tliis  section  shows  very  -well  the  aberrant  downward  growth  of   the  super- 
ficial epithelium  of  the  skin.      Winckel  No.  3,  without  ocular.      (From  the  author's  collection.) 

The  epithelial-cell  clusters  invariablj'  lie  within  the  Ijmiph  spaces  and  extend 
by  way  of  the  lymph  channels.  In  hardened  sections,  in  which  the  epithelial 
cells  have  shrunk  away  from  their  boundaries,  it  is  often  possible  to  detect  a 
layer  of  endothelium  lining  the  alveolus,  similar  to  that  lining  the  lymphatics. 

In  a  general  way,  the  cells  forming  a  carcinoma  resemble  those  of  the  epithelial 
structures  from  which  they  arise.  Close  study,  however,  will  reveal  some  nota- 
ble differences.  The  carcinoma  cells  are  often  larger  and  possess  larger  nuclei ; 
there  is  considerable  variation  in  shape;  and  degenerative  changes  are  often  to  be 
observed  in  the  protoplasm.  Single  cells  of  relativelj'  great  size,  containing  a  sin- 
gle large  nucleus,  can  occasionally  be  seen;  or,  again,  cells  may  be  seen  which  con- 
tain a  multitude  of  nuclei.  The  nuclei  are  rich  in  chromatin  and  stain  deeply. 
The  process  of  cell  division  is,  moreover,  abnormal.     In  place  of  simple  division 


TUMORS  AND  TUMOR  FORMATION.  357 

of  the  nuclei,  we  get  the  most  compUcated  and  irregular  nuclear  figures.  Some 
of  the  cells  contain  vacuoles  filled  with  fat  or  hyalin  and  appear  to  be  phago- 
cytic, for  they  may  enclose  leucocytes,  red  corpuscles,  or  plasma  cells.  In  fine, 
the  differences  taken  together  indicate  an  overplus  of  vegetative  energy.  The 
degenerations  so  commonly  found  are  a  natural  accompaniment  of  this,  the 
cells  growing  so  fast  that  they  cannot  obtain  sufficient  nourishment. 

The  clumps  of  epithelial  cells,  lying  in  the  alveolar  spaces,  present  great  varia- 
tions in  size  and  shape.  As  a  rule,  the  newly  formed  epithelium  forms  a  solid  mass 
which  ramifies  in  the  connective  tissue,  not  unlike  the  roots  of  a  tree.  At  the 
periphery  of  the  main  mass,  small  isolated  clusters  of  cells  may  often  be  found, 
having  no  visible  connection  with  the  rest. 

The  distinction  between  cells  and  stroma  is  usually  weW  preserved,  but  if  the 
stroma  be  loose  and  cellular  it  is  hard  to  determine  the  limits  of  the  new  growth. 
In  the  case  of  loose  connectiA'e  tissue  and  fat  the  epithelial  cells  grow  wildly  in  all 
directions,  so  that  the  alveolar  arrangement  is  lost.  We  often  find  the  carcinoma 
cells  extending  in  long  rows  as  a  somewhat  diffuse  infiltration. 

It  should  be  noted  that  the  carcinoma  cells  preserve,  so  far  as  may  be,  the 
physiological  characters  of  the  epithelium  from  which  they  are  derived.  If  we  take 
the  case  of  the  epithelioma  of  the  skin,  the  finger-like  processes  that  invade  the 
deeper  tissues  are  composed  of  cells  that  develop,  grow  old,  and  die,  just  as  do 
those  of  the  superficial  epithelium.  We  find,  for  example,  that  the  cells  at 
the  periphery  of  the  cell  masses  correspond  with  those  of  the  Malpighian  layer. 
As  we  proceed  toward  the  centre  the  cells  gradually  become  flattened  and  are 
converted  into  keratohyalin.  This  gives  rise  to  curious  translucent  bodies  having 
a  concentric  lamination  resembling  the  layers  of  a  pearl  or  onion.  These  are  the 
"  epithelial  pearls  "  or  "  cell  nests  "  that  are  so  conspicuous  a  feature  of  the  epithe- 
liomata  of  the  skin  (Fig.  112).  The  same  tendency  is  manifested  in  the  columnar- 
celled  carcinoma  of  the  rectum.  The  proliferating  epithelial  cells  come  to  be 
arranged  side  by  side,  their  long  axes  pointing  in  the  same  general  direction.  As 
a  result  we  get  the  columnar  cells  grouping  themselves  about  a  central  lumen, 
thus  reproducing  more  or  less  faithfully  the  original  tubules  and  acini.  The  regu- 
larity of  this  formation  is  often,  however,  lost  in  consequence  of  the  exuberant 
growth,  so  that  groups  of  cells  become  forced  into  the  cavity  and  there  form 
acini,  solid  masses,  and  complicated  loops.  Pressure,  too,  of  the  rapidly  growing 
cells  will  naturally  modify  the  arrangement.  Carcinomata  of  the  thjToid  also 
give  rise  to  secondary  growths  that  assume  the  alveolar  structure  of  the  normal 
gland  and  may  even  produce  colloid.  This  tendency  to  retain  the  original  char- 
acteristics of  the  parent  cells  is,  as  one  would  expect,  most  marked  in  the  case  of 
slowly  growing  tumors,  while  it  is  lost  in  the  more  exuberant  growths.  It  may, 
moreover,  be  present  in  one  part  of  a  tumor  and  absent  in  another. 

Mention  has  been  made  above  of  degenerative  disturbances  which  are  not 
infrequently  present  in  the  specific  cells  of  carcinomata.     These  take  the  form  of 


358  AMERICAN  PRACTICE  OF  SURGERY. 

simple  coagulation,  of  colliquative  necrosis,  or,  again,  of  colloidal  and  hyaline 
transformation.  Necrosis  is  apt,  of  course,  to  occur  in  rapidly  growing  tumors, 
where  the  vascular  mechanism  is  unable  to  keep  pace  with  the  epithelial  pro- 
liferation. Necrosis  usually  occurs  in  the  centre  of  the  cell  masses,  or,  in  other 
words,  at  the  point  most  remote  from  the  nutrient  blood-vessels. 

From  the  histologist's  point  of  view  the  appearance  of  the  cells  constituting  a 
carcinoma  forms  a  ready  means  of  classification.  Thus  we  may  recognize  a  squa- 
mons-celled  carcinoma  (carcinoma  plano-cellulare),  a  round-celled  carcinoma 
(carcinoma  globo-cellulare),  and  a  cylindrical-celled  carcinoma  (carcinoma  cy- 
lindro-cellulare).  It  should  be  remarked,  however,  that  while  the  carcinoma  cells 
tend  to  reproduce  the  characters  of  the  epithelial  cells  from  which  they  spring,  yet 
they  do  not  always  perpetuate  these.     The  more  rapidly  growing  the  tumor  and 


Fig.  112. — Epithelial  Pearl  or  "Cell-Nest,"  from  an  Epithelioma  of  the  Lip.      W^inckel  No.  6, 
without  ocular.      (From  the  author's  collection.) 

the  farther  removed  its  cells  from  their  original  progenitors,  the  more  widely  do  the 
specific  carcinoma  cells  deviate  from  the  type.  Thus,  a  carcinoma  of  the  cylin- 
drical-cell type  may  in  parts  consist  of  clusters  and  off-shoots  of  round  cells.  This 
has  been  by  some  termed  metaplasia  of  epithelium.  It  is  more  likely,  how- 
ever, that  the  round  cells  are  merely  young  and  immature  forms  of  cylindrical 
cells.  This  is  often  well  illustrated  in  the  case  of  metastases  which  may  be 
quite  unlike  the  parent  growth. 

The  sqiiamous-ceUed  carcinoma  (epithelioma)  may  arise  in  any  part  of  the  body 
where  stratified  pavement  epithelium  is  found.  It  occurs,  therefore,  in  the  skin, 
especially  that  of  the  face  and  lip,  in  the  buccal  mucous  membrane,  the  tongue, 
oesophagus,  anus,  vulva,  vagina,  vaginal  portion  of  the  cervix  uteri,  penis,  and 


TUMORS  AND  TUMOR  FORMATION.  359 

conjunctiva.  Rarely,  epitheiiomata  may  arise  from  papillary  warts  and  ntevi, 
from  atheroma  cysts,  and  from  dermoids,  ^'ery  exceptionally,  a  squamous-celled 
carcmoma  may  originate  from  parts  that  contain  no  squamous  cells.  This  is 
known  to  occur  in  the  uterus.  "\'on  Rosthorn  and  Zeller  have  described  a  meta- 
plasia of  the  columnar  cells  lining  the  uterine  cavity  into  pavement  cells,  and 
from  these  a  squamous-celled  epithelioma  may  develop. 

A  squamous-celled  epithelioma  results  from  the  invasion  of  tissues  and  organs 
by  proliferating  epithelial  cells  deri-\'ed  from  stratified  pavement  epithelium  con- 
stituting a  protecting  membrane  or  lining  a  cavity. 

Histologically,  it  consists  of  a  supporting  stroma  usually  of  connective-tissue 
or  muscle,  or  both,  in  which  are  alveoli  filled  with  cells  of  epithelial  type.  The 
cell  clusters  usually  appear  to  be  distinct  and  isolated,  but  serial  sections  show 
that  they  are  united  at  various  levels  by  lateral  processes,  so  that  the  epithelial 
masses  have  really  a  plexiform  arrangement.  In  the  epitheiiomata  of  the  skin, 
the  cells  at  the  periphery  of  the  alveoli  are  round,  cubical,  or  short  columnar,  and 
are  placed  at  angles  to  the  surface  of  the  stroma,  in  this  resembling  the  germinal 
cells  of  the  rete Malpighii.  Many  of  them  can  be  recognized  as  "  prickle ' '  cells.  As 
we  approach  the  centre,  the  cells  become  more  flattened  and  spindle-shaped, 
and  gradually  lose  their  nuclei.  The  central  cells,  as  before  mentioned,  retaining 
their  physiological  peculiarities,  are  gradually  transformed  into  an  almost  struct- 
ureless keratohyalin  material.  The  concentrically  arranged  cell  masses  may  cal- 
cify at  the  centre,  liquefy,  or  swell  up,  or  may  become  converted  into  colloid. 
They  are  not  always  found  in  epitheiiomata,  or,  if  they  are,  they  are  present 
in  very  small  numbers. 

Carcinomata  of  this  type  are  particularly  apt  to  break  down  on  the  surface, 
thus  forming  an  ulcer,  the  edges  of  which  are  soft  and  swollen. 

A  special  form  of  epithelioma  of  the  skin,  that  demands  a  word  or  two,  is  the 
so-called  "rodent  ulcer."  This  begins  as  a  small  ulcer  of  the  skin,  not  infre- 
quently on  the  face  near  the  eyelids.  It  spreads  irregularly  at  the  periphery, 
while  the  older  parts  cicatrize  and  heal,  again  becoming  covered  with  epithelium. 
The  growth  is  essentially  chronic  and  may  last  many  years.  Histologically,  it  is 
a  superficial  epithelioma  of  the  skin,  but  must  be  regarded  as  the  least  malignant 
form  of  this  type  of  cancer. 

The  rotrnd-celled  carcinoma  is  composed  of  spaces  filled  with  round  cells  or  cells 
which  have  been  rendered  polyhedral  from  pressure.  Since  the  various  diame- 
ters of  the  cells  are  approximately  equal  they  have  been  termed  isodiametric. 

Round-celled  carcinomata  arise  in  glands,  like  the  mamma,  salivary  glands, 
and  liver,  and  in  glandular  tumors,  that  contain  isodiametric  epithelium.  Occa- 
sionally, they  may  arise  from  the  cylindrical  epithelivim  of  mucous  surfaces  and 
glands,  the  cells  of  which  have  been  transformed  into  the  isodiametric  type. 

Histologically,  we  may  recognize  a  large  alveolar  round-celled  form,  in  which 
the  spaces  contain  a  large  mmiber  of  isodiametric  cells  closely  packed  together, 


360  AilERICAN  PRACTICE  OF  SURGERY. 

and  a  s77iaU  alveolar  round-celled  variety,  in  which  a  smaller  number  of  cells, 
iisually  from  two  to  ten,  are  to  be  found. 

The  cylindrical-celled  carcinoma  originates  in  mucous  membranes,  glands, 
ducts,  and  tubules  provided  with  cylindrical  epithelium.  We  find  it,  therefore, 
very  commonly  in  the  stomach  and  intestines.  In  a  typical  case,  the  alveoli  con- 
sist of  cylindrical  cells  arranged  so  as  to  enclose  a  central  cavity,  in  this  suggest- 
ing the  normal  structure  of  the  gland.  Certain  of  the  cells  in  question  are  goblet 
cells.  The  lumina  generally  contain  fluid,  mucin,  and  disintegrated  cells.  The 
cells  lining  the  alveoli  may  form  a  single  layer,  or,  again,  they  may  be  strati- 
fied. Here  and  there  the  smaller  alveoli  can  be  seen  to  contain  masses  of 
round  cells,  which  are  solid  buds  of  young  growing  cells  springing  from  the 
cylindrical  cells  lining  the  spaces.  These  may  be  so  numerous  as  to  constitute 
the  tvunor  a  transition  form  between  the  C3dindrical-celled  and  the  round-celled 
carcinoma. 

The  shape  of  the  epithelial  cells  closelj'  resembles  that  of  the  cells  of  the  normal 
mucous  membrane,  and  it  is  curious  how  faithfully  the  glandular  appearance  of 
the  new  growth  is  preserved.  A  reference  to  Fig.  113  will  show  how  closely  such  a 
carcinoma  may  resemble  the  simple  adenoma.  Certain  features,  however,  will 
aid  us  in  making  the  differential  diagnosis.  Thus,  cylindrical-celled  carcinomata 
usuallj'  ulcerate  early,  much  earlier  than  do  the  adenomata.  The  important 
clincliing  point  is,  however,  the  presence  of  epithelial  cell  masses  in  parts  where 
normally  epithelium  is  not  present.  In  the  adenoma,  say  of  the  intestinal  mu- 
cous membrane,  cell  masses  and  alveoli  are  produced  which  closely  resemble  the 
growing  processes  of  the  carcinoma.  There  is  this  important  difference,  how- 
ever, the  proliferation  of  the  cylindrical  cells  in  the  adenoma  is  entirely  confined 
to  the  muco.sa ;  in  other  words,  it  lies  above  the  muscularis  mucosie.  In  the 
cjdindrical-celled  carcinoma,  on  the  other  hand,  the  cells  soon  break  these  bonds, 
pass  into  the  submucosa,  and  eventually  invade  the  muscular  la}'ers  and  the 
neighboring  structures.  Goblet  cells,  which  are  so  important  a  feature  of  the 
gastro-intestinal  mucous  membrane,  are  fairly  numerous  in  the  adenoma,  while 
they  are  much  rarer  in  the  carcinoma. 

Having  discussed  the  nature  and  appearance  of  the  epithelial  cells  that  con- 
stitute a  carcinoma  we  pass  on  to  consider  the  character  of  the  supporting  stroma. 
This  also  presents  considerable  variations.  ^^Hiile  it  forms  part  of  the  tmiior  mass 
and  grows  with  it,  it  camiot  be  said  to  be  an  integral  part  of  the  timior.  The 
stroma  of  the  tumor  represents  in  part  the  normal  tissues  of  the  locality  that  has 
been  invaded  by  the  epithelial  cells.  Thus,  in  an  epithelioma  of  the  skin  the 
stroma  consists  of  the  subcutaneous  connective  tissue  and  fat  together  ^^•ith  seba- 
ceous and  sudoriparous  glands.  As  the  tumor  grows  there  is  undoubtedly  a  new 
formation  of  the  interstitial  connective  tissue  advancing  -pari  pass^l  with  it.  This 
may  possibly  be  interpreted  as  an  attempt  to  form  a  vascular  tissue  competent  to 
carry  nutriment  to  the  growing  epithelial  structures.     Possibly,  too,  it  is  to  some 


TUMORS  AND  TUIVIOR  FORMATION 


361 


extent  a  reaction  on  the  part  of  the  stroma  resulting  from  tlie  irritation  produced 
by  the  presence  of  cells  foreign  to  the  normal  tissues. 

The  stroma  usually  consists  of  fibrous  connective  tissue,  though  in  excep- 
tional cases  it  may  be  composed  of  muscle,  as  in  carcinoma  of  the  uterus,  or  of 
bone,  as  in  secondary  carcinoma  of  bone.  Here  and  there  in  the  stroma  can  be 
seen  isolated  clumps  or,  sometimes,  a  diffuse  infiltration  of  round  cells,  resem- 
bling the  h'mphoid  cells  of  the  lymph  nodes  and  the  lymphocytes  of  the  blood. 
Plasma  cells  are  present  also,  but  are  somewhat  less  nvunerous.  With  this  there 
are  evidences  of  proliferation  of  the  connective-tissue  cells  proper,  but  this  is 
usually  in  the  background.  Occasionally  the  proliferation  is  so  marked  that  the 
interstitial  stroma  comes  to  resemble  a  sarcoma.     Occasionally  giant  cells  can 


Fig.  113. — Columnar-celled  Adeno-carcinoma  of  the  Rectum.      Winckel  No.  3,  without  ocular. 
(From  the  author's  collection.) 

be  seen  in  the  stroma,  similar  to  those  sometimes  found  in  the  neighborhood  of 
foreign  bodies. 

The  relative  amounts  of  epithelial-cell  masses  and  of  stroma  varj-  greatly 
in  different  tumors  and  even  in  different  parts  of  the  same  tumor.  This  forms 
a  convenient  basis  on  which  to  divide  carcinomata  according  to  their  gross 
appearances.  If  the  fibrous  connective  tissue  greatly  predominate  we  speak 
of  a  scirrhous  carcinoma.  In  such  cases  the  epithelial-cell  clusters  are  small, 
often  attenuated,  and  atrophic-looking.  If  the  epithelial  cells  be  numerous 
and  arranged  in  small  clusters  bounded  by  a  delicate  connective-tissue  wall, 
we  have  an  alveolar  carcinoma.  If  the  stroma  be  scarcely  apparent  so  that 
we  get  a  soft  brain-like  growth,  we  call  it  a  medullary  or  encephuloid  carcinoma. 
A  carcinoma  in  which  stroma  and  epithelial  elements  are  about  equally  divided 
is  termed  a  simple  carcinoma. 


362 


AMERICAN  PRACTICE  OF  SURGERY. 


The  margin  of  a  carcinoma  is  rareh'  sliarp.  The  greatest  growth  is  at  the 
peripherj^,  and  the  tumor  extends  in  lines  into  the  adjacent  tissues.  There 
is  never  any  attempt  at  the  formation  of  a  capsule.  In  the  neighborhood 
of  the  growth  can  often  be  seen  small  foci  of  epithelial  cells  either  separated 
from  the  main  mass  or  attached  to  it  by  a  delicate  thread  of  tissue.  The  invasion 
and  destruction  of  the  healthy  tissues  in  the  immediate  vicinity  of  the  growth 
are  a  marked  feature.     The  destruction  of   the  tissues  seems  to  be  brought 


-Carcinoma  of  the  Lesser  Curvature  of  the  Stomach,  with  Ulceratii 
Museum  of  McGiil  University.) 


(Pathological 


about,  not  so  much  by  pressure  or  by  phagocytic  action  of  the  carcinoma  cells, 
as  by  simple  lack  of  nutrition,  all  the  available  pabulum  being  appropriated 
by  the  tumor. 

Secondary  Changes  in  Carcinomata. — I  have  above  mentioned  the  fact  that 
degenerative  phenomena  are  commonly  to  l^e  found  in  carcinoma  cells,  ^^^^en 
the  growth  is  of  any  size  these  become  quite  marked.  Thus,  in  the  centre  of  the 
cell  clusters,  we  get  fatty  degeneration,  vacuolation,  atrophy,  and  even  necrosis. 
In  this  way  large  portions  of  the  alveolar  contents  are  destroyed.  The  nuclei 
disintegrate,   the   cytoplasm   fragments,  and  we  get  a  dirty-looking  granular 


TUMORS  AND  TUilOR  FORMATION. 


363 


detritus  that  stains  badly.  'N^lien  the  necrosis  is  superficial  it  leads  to  ulcera- 
tion (Fig.  114).  In  internal  carcinoma ta,  ag  for  example  those  of  the  liver,  the 
detritus  is  in  part  absorbed,  and  the  nodules  formed  by  new  growth  soften  and 
become  depressed  in  the  centre,  or  "umbilicated"  as  it  is  called. 

Certain  of  the  degenerative  changes  are  so  striking  that  they  stamp  the  tumor 
as  something  out  of  the  ordinary.  An  instance  of  this  is  the  colloid  or  gelatinous 
carcinoma,  foimd  most  often  in  the  alimentary  tract  and  mamma,  less  often  in 
the  ovary.  It  forms  a  nodular  growth  or  a  diffuse  infiltration.  On  section  the 
tumor  shows  in  some  part  or  other,  or  possibly  throughout,  a  characteristic  trans- 
lucent, gluey,  or  gelatinous  appearance.  This  is  due  to  a  mucinous  or  gelatinous 
degeneration  of  the  epithelial-cell  clusters.  The  carcinoma  cells  may  in  time 
entirely  disappear,  and  the  spaces  are  then  filled  with  a  homogeneous,  glassy 


Fig.  115. — Colloid  Carcinoma.  Winckel  No.  3,  without  ocular.  The  carcinoma  cells  are  greatly 
degenerated  and  have  been  replaced  by  colloid,  which  can  be  recognized  as  long  stringy  fibrils. 
(From  the  author's  collection.) 

substance  that  under  the  microscope  appears  as  structureless  fibrils  striking  a 
purple  color  with  h^ematoxylin  (Fig.  115).  In  other  cases  the  fibrous  stroma 
undergoes  myxomatous  transformation — carcinovia  myxomatodes, — either  alone 
or  with  mucinous  transformation  of  the  epithelial  cells  as  well.  Thus  the  whole 
growth  may  become  translucent  and  gelatinous. 

A  rarer  form  of  carcinoma  is  that  in  which  hyaline  transformation  of  certain  of 
the  epithelial  cells  or  of  the  stroma  takes  place — carcinoma,  cylindromatosiim.  It 
occurs  in  the  skin,  the  mtestine,  and  in  glands. 

Pigmented  carcinomata — melano-carcinomata — have  been  described,  but  are 
still  rarer.  The  pigment  lies  partly  in  the  epithelial  cells  and  partly  in  the  stroma, 
giving  the  tumor  a  gray,  brownish,  or  black  color. 


364 


AMERICAN  PRACTICE  OF  SURGERY. 


Methods  of  Extension  and  Metastasis. — If  we  examine  a  growing  carcinoma, 
we  find  tliat  it  is  sending  out  at  tlie  periphery  processes  of  epithelial  cells  into  the 
tissue  spaces,  spaces  that,  as  we  have  alreadj'  seen,  are  to  be  regarded  as  the  ulti- 
mate radicles  of  the  lymph  chamiels.  This  is  termed  extension  by  infiltration 
(Fig.  116).  Some  few  carcinoma ta  are  almost  as  sharply  defined  at  the  margins 
as  a  benign  growth,  but  in  most  there  is  undoubted  infiltration  of  the  surrounding 
soft  parts,  and  in  some  this  may  be  quite  far-reaching.  Sometimes,  also,  we 
find  small  nodules  at  some  little  distance  from  the  periphery,  similar  in  appear- 
ance to,  but  quite  distinct  from,  the  primary  growth.  These  are  the  result 
of  minute  emboli  of  carcinoma  cells  within  the  l3''mphatic  channels  leading  from 
the  part.     This  is  known  as  extension  by  dissemination. 


-Carcinoma  of  the  Stomach.      This  spc 
muscular  wall  with  epithelial  cells 


ui'ii  sh()\vs  very  clearly  the  infiltratii 
(_Frorn  the  author's  collection.) 


Small  clusters  of  epithelial  cells  ma}'  also  break  away  from  the  main  mass  of 
the  growth  and  be  carried  by  the  lymphatics  or,  occasionally,  by  the  blood  stream, 
to  distant  parts,  where  they  set  up  independent  foci  of  disease.  This  phenomenon 
is  called  metastasis.  In  general  the  first  manifestation  of  metastasis  occurs  in  the 
regional  lymph  nodes  nearest  the  primary  growth  (Fig.  117).  If  we  examine  one 
of  these  nodes  in  the  early  stage  of  the  process,  we  find  small  foci  of  epithelial 
cells  at  the  periphery  of  the  node  in  close  relationship  to  the  afferent  lymphatic 
channels  and  sinuses.  At  first,  one  sees  the  lymphoid  cells  between  the  epithelial- 
cell  masses,  but  soon  they  atrophj^  and  their  place  is  taken  by  connective  tissue. 
The  metastases  in  general  resemble  the  primary  tumor,  except  that  the}'  are  not 
so  apt  to  retain  the  functional  peculiarities  of  the  cells  from  which  they  are  ulti- 
mately derived.  Thus,  in  metastases  from  an  epithelioma  of  the  skin  we  do  not 
so  often  get  the  formation  of  the  epithelial  "pearls,"  and  in  adeno-carcinomata 


TUMORS  AND  TUMOR  FORMATION.  365 

the  glandular  appearance  of  the  original  growth  is  not  so  completely  preserved. 
When  the  regional  lymph  nodes  are  thoroughly  infiltrated,  the  masses  of  carci- 
noma cells  pass  out  by  the  efferent  lymphatics  and  invade  the  system  of  nodes 
next  in  order,  or  cancerous  emboli  may  pass  through  the  first  series  of  nodes 
without  involving  them,  and  attack  those  more  remote. 

Metastasis  by  the  blood  stream  is  rather  uncommon  in  the  case  of  the  carci- 
nomata,  though  it  is  the  rule  with  the  sarcomata.  Carcinomata  of  the  stomach 
and  intestines,  however,  commonly  spread  to  the  liver  through  the  portal  system, 
(Fig).  118,  and  carcinomata  of  vascular  regions,  like  the  penis,  may  extend 
through  the  blood  sinuses  and  vessels.  The  new  growth  may  directly  invade  the 
vessels  destroying  the  wall  and  appearing  within  the  lumen,  or  may  reach  the 


Fig.  117. — Secondary  Invasion  of  a  Lymph  Node  with  Columnar-Celled  Carcinoma.      Winckel 
No.  3,  without  ocular.      (From  the  author's  collection.) 

blood  through  the  lymph-vascular  system.  Generally  speaking,  emboli  from  car- 
cinomata of  the  gastro-intestinal  tract  reach  the  liver,  those  from  tmnors  situ- 
ated elsewhere  reach  the  lungs.  Exceptionally,  invasion  may  take  place  in  a 
direction  opposite  to  the  course  of  the  lymph  stream — retrograde  embolism. 

Extension  of  a  carcinoma  may  also  take  place  by  implantation.  In  carcinoma 
of  the  kidney,  secondary  tumors  may  arise  along  the  ureter  and  in  the  bladder. 
In  carcinoma  of  the  ovary,  secondary  nodules  may  appear  in  the  Fallopian  tubes 
and  in  the  peritoneum.  In  the  intestine,  small  secondary  growths  may  be  found 
in  the  mucosa  below  the  original  mass.  In  all  these  cases  the  dissemination  of  the 
growth  appears  in  large  part  to  be  determined  by  gravity. 

Carcinoma  in  its  extension  always  takes  the  line  of  least  resistance,  and  we 
find  it  spreading  along  the  tissue  interstices,  and  along  the  perineural  and  perivas- 
cular lymphatics. 


366 


AMERICAN  PRACTICE  OF  SURGERY. 


III.  THE  TERATOID  TUMORS. 

In  the  foregoing  pages  we  have  had  under  discussion  tumors  that  are  members 
of  the  great  family  commonly  known  as  the  Blastomata.  It  remains  for  us  to  con- 
sider the  second  main  group,  the  Teratomata. 

The  blastomata  have  been  dealt  with  at  considerable  length,  comprising  as  they 
do  the  vast  majority  of  tumors  commonly  met  with.  The  teratomata,  being  much 
rarer,  are  of  not  so  much  practical  importance  to  the  surgeon,  though  they  are  of 
the  greatest  importance  in  regard  to  the  question  of  tumor  formation.  We  will, 
therefore,  in  this  place  consider  them  only  in  a  sketchy  way. 

A  teratoma  is  a  tumor  the  characteristic  feature  of  which  is  that  it  is  com- 
posed of  cells  or  tissues  that  normally  do  not  occur  in  the  affected  part,  or  at  least 
are  not  present  at  the  period  of  bodily  development  at  which  the  growth  mani- 


FiG.  lis. — Secondary  Carcinoma  of  the  Liver.      Winckel  No.  3,  witliout   ocular.      (From  tlie  autlior's 

collection.) 

fests  itself.  The  simplest  form  of  teratoma  is  represented  by  a  single  tissue  or  a 
cyst  {simple  teratoid  tumor  or  cyst),  but  as  a  rule  more  than  one  tissue  and  more 
than  one  germ  layer  are  represented  (mixed  tumor).  The  term  "teratoma"  is 
often  applied  in  a  narrower  sense  to  the  more  complex  growths,  while  tumors 
consisting  of  derivatives  of  all  three  primitive  cell-layers  are  called  embrijoid 
tumors  or  einbryomata.  The  tissues  entering  into  the  composition  of  teratomata 
arise  either  from  the  Anlage  of  the  affected  individual  {monogerminal,  endogenous, 
or  autochthonous  teratoviata) ,  or  from  those  of  a  second  individual  (bigerminal 
ectogenous  teratomata;  fa'tus  in  fwtu). 

Occasionally,  sarcomatous  or  carcinomatous  transformation  may  occur  iu 
the  tissues  of  a  teratoma,  constituting  a  malignant  teratoma. 


TUMORS  AND  TUMOR  FORMATION.  367 

As  all  teratomata  are  due  to  proliferation  of  misplaced  or  redundant  cells,  it 
is  evident  that  we  may  meet  with  all  degrees-  of  complexity,  from  the  simplest 
epidermoid  or  implantation  cyst  to  the  most  complicated  malformation  and  mon- 
strosity. For  information  on  the  latter  phase  of  the  subject  the  reader  is  referred 
to  works  on  teratology. 

Warthin  gives  the  following  classification  of  teratomata,  which  is  as  simple 
as  any: 

1.  Simple  teratoid  tumors.  f  n  . 
[  Ectodermal.  •' 

2.  Simple  teratoid  cysts.   -{  Mesodermal. 
Teratomata :  \  (.  Entodermal. 

3.  Complex    teratomata  and  teratoid  cysts    (embryoid    tumors 
and  embryoniata). 

4.  Malignant  teratomata. 

Simple  teratoid  tumors  consist  of  a  single  variety  of  tissue  or  at  most  of  only 
a  few  forms  of  tissue.  Tumors  belonging  to  this  group  are  the  hypernephro- 
mata,  rhabdo-myomata,  chondroma  of  the  mamma,  salivary  glands,  skin,  testis, 
etc.;  adeno-myoma  of  the  uterus  and  broad  ligament;  leiomyoma  of  the  kidney; 
osteoma  of  muscles,  skin,  mamma,  tongue ;  lipoma  of  the  meninges ;  coccygeal 
and  lumbo-sacral  lipomata  and  myo-lipomata.  Most  of  the  tumors  of  this  group 
are  to  be  regarded  as  heterotopic  tumors,  arising  from  autochthonous  foetal 
"  Anlage,"  but  some  possibly  may  be  bigerminal  inclusions. 

Simple  Teratoid  Cysts. — Ectodermal  teratoid  cysts  include  cysts  lined  with 
stratified  squamous  epithelium,  without  other  skin  structures  (epidermoid  cysts), 
and  cysts  whose  wall  contains  hairs,  glands,  and  fat  (dermoid  cysts),  in  this  resem- 
bling skin.  Epidermoids  are  sometimes  due  to  injury,  as  in  the  so-called  implan- 
tation dermoids.  I  have  met  with  one  such  case  where  the  penetration  of  the 
palm  of  the  hand  with  a  blunt  piece  of  wood  was  followed  by  the  formation  of  a 
small  cyst  of  epidermoid  character.  One  of  the  most  interesting  forms  of  epider- 
moid is  the  cholesteatoma,  fouird  in  the  meninges,  the  hypophysis  cerebri,  and  the 
middle  ear,  among  other  places.  It  is  a  spherical  or  nodular  tumor,  varying  in 
size  from  that  of  a  pea  to  that  of  an  orange,  and  on  section  has  a  glistening,  waxy 
appearance.  Histologically,  it  is  composed  of  flattened,  scale-like  cells,  devoid 
of  nuclei,  arranged  in  a  laminated  fashion.  The  central  portion  tends  to  degen- 
erate and  is  often  filled  with  a  pultaceous  mass  containing  plates  of  cholesterin. 

Mesodermal  and  entodermal  cysts  originate  in  misplaced  entodermal  and  mes- 
odermal "Anlage,"  or  the  persistence  of  foetal  ducts  and  glands.  They  are  lined 
with  columnar  epithelium,  sometimes  ciliated,  and  are  found  most  frequently  in 
the  female  genital  tract,  less  often  in  the  peritoneal  cavity,  intestine,  close  to  the 
trachea  and  bronchi,  and  in  the  lungs,  pleura,  tongue,  neck,  liver,  and  kidneys. 


368  AMERICAN  PRACTICE  OF  SURGERY. 

Complex  teratoid  tumors  and  cysts  are  found  in  the  same  situations  as  the 
forms  above  described  but  are  commonly  met  with  in  the  sexual  glands  and  about 
the  coccyx.  They  consist  of  a  great  variety  of  cells  and  tissues,  squamous  and 
columnar  epithelium,  ciliated  epithelium,  skin,  nerve,  fat,  striped  and  unstriped 
muscle,  cartilage,  bone,  and  glands.  The  tissue  represented  may  be  adult  or  im- 
mature.    The  ovarian  dermoid  may  be  taken  as  a  type. 

This  is  a  thick-walled  cyst  filled  with  a  fatty,  pultaceous  substance,  lanolin, 
and  sometimes  wisps  of  hair.  At  one  point  of  the  inner  wall  is  a  prominence  cov- 
ered with  hairs  and  occasionally  containing  teeth.  This  may  contain  masses  of 
bone,  suggesting  a  jaw.  The  prominence  referred  to  consists  of  all  the  structures 
of  the  skin.  The  cyst  is  lined  in  places  with  ciliated  epithelium.  In  the  cyst  wall 
derivatives  of  all  the  three  primitive  germinal  layers  may  be  found. 

Malignant  Teratomata. — Any  of  the  above-mentioned  tumors  and  cysts  may 
undergo  secondary  malignant  transformation.  Some  behave  as  malignant  from 
the  first.  The  more  complicated  solid  growths,  especially  those  of  the  genital 
tract  and  mediastinum,  are  those  most  apt  to  exliibit  this  tendency. 

A  word  or  two  should  be  said  about  the  chorio-epitheliovia  malignum,  some- 
times called  deciduoma  malignum..  Inasmuch  as  this  tumor  is  derived  from  the 
cells  of  one  individual  proliferating  within  the  tissues  of  another,  it  can  properly 
be  included  with  the  teratomata. 

Chorio-epithelioma  malignum  is  a  new  growth  originating  in  the  foetal  epiblast 
of  the  chorionic  villi.  It  grows  rapidly,  infiltrates,  and  forms  metastases.  The 
growth  is  polypoid  or  fungous,  projecting  into  the  cavity  of  the  uterus,  is  of  red- 
dish color,  and  of  soft,  friable  texture.  Microscopically,  the  tumor  resembles  a 
carcinoma  or  sarcoma,  or  both,  but  there  may  be  in  addition  syncytial  or  plas- 
modial  masses,  or  even  \\\Y\.  The  growth  originates  in  the  proliferation  of  the 
syncytiimi  and  the  Langhans'  layer  of  the  chorionic  villi.  The  syncytium  is  thick- 
ened and  the  cells  of  the  Langhans'  layer  tend  to  grow  toward  the  surface.  The 
deeper  parts  present  an  alveolar  arrangement.  The  resulting  tumor  has  no 
stroma  and  no  blood-vessels.  Hemorrhage  into  the  growth  and  necrosis  are 
common  features. 

THE  RESULTS    OF  TUMOR  FORMATION. 

All  tumors  produce  effects  by  their  size  and  weight.  The  neighboring  struct- 
ures are  pressed  upon  and  as  a  result  undergo  atrophy,  or,  if  movable,  they 
may  be  dislocated.  Pressure  upon  blood-vessels  leads  to  obstruction  of  the 
circulation,  oedema,  thrombosis,  embolism,  or  necrosis.  Pressure  upon  nerves 
causes  pain  and  may  lead  to  paralyses.  Pressure  upon  the  ducts  of  glands  may 
result  in  retention  of  secretion  and  dilatation  of  the  organ.  Tumors  on  the 
extremities  may  interfere  with  locomotion  and  the  free  action  of  joints.  Pedun- 
culated growths,  especially  when  of  large  size,  are  apt  to  undergo  necrosis  and 
ulceration,  owing  to  the  interference  with  nutrition  that  eventually  takes  place. 


TUMORS  AND  TUMOR  FORMATION.  369 

Secondary  infection  may  result  in  local  inflammation  and  even  generalized  septic 
manifestations. 

Malignant  tumors,  in  addition  to  the  conditions  mentioned  above,  which  are 
largely  the  result  of  mechanical  forces,  and,  therefore,  are  particularly  well  exem- 
plified in  the  case  of  the  benign  growths,  possess  the  power  of  infiltrating  and 
destroying  the  structures  in  which  they  may  be  growing.  Their  power  of  metas- 
tasis has  already  been  referred  to.  When  superficial,  carcinomata  may  ulcerate 
and  become  inflamed.  The  malignant  growths  also  give  rise  to  a  peculiar  form 
of  generalized  marasmus,  known  as  cancerous  cachexia.  This  is  manifested  by 
great  weakness,  wasting  of  substance,  and  an  earthy  color  of  the  skin.  It  owes 
its  origin  in  part  to  the  pain  and  discomfort  caused  by  the  growth,  and  in  part 
to  the  interference  with  the  functions  of  the  body,  notably  digestion;  it  may 
also  in  some  measure  be  attributed  to  septic  absorption ;  and,  finally,  it  should 
to  some  extent  be  considered  a  systemic  manifestation  of  poisonous  substances 
emanating  from  the  new  growth. 


THEORIES  OF  TUMOR  FORMATION. 

By  THEODORE  A.  McGRAW ,  M.D.,  LL.D.,  Detroit,  Michigan. 


True  tumors  or  neoplasms  have  been  aptly  defined  as  "new  growths  of  tis- 
sue which  have  no  physiological  connection  with  the  body."  The  essential 
features  of  this  definition  have  been  generally  accepted,  but  there  is  hardly  a  pa- 
thologist of  note  who  has  not  tried  to  improve  it  by  variations  in  the  mode  of 
statement  or  by  explanatory  additions.  These  efforts  have  generally  ended  in 
failure,  for  the  reason  that  it  is  impossible  to  define  exactly  and  minutely  condi- 
tions which  we  do  not  imderstand.  We  speak  of  the  physiological  connection 
of  normal  tissues  with  the  organism  of  which  they  form  part,  because  we  have 
become  assured,  from  observing  certain  constant  phenomena,  of  the  existence 
of  physiological  laws,  which  are  violated  in  the  growth  of  every  neoplasm, 
but  our  knowledge  is  so  vague  and  indefinite,  and  the  mechanisms  by  which 
vital  processes  are  carried  on  are  so_  beyond  all  human  understanding,  that  we 
cannot  formulate  them  in  terms  which  convey  exact  ideas.  We  cannot,  how- 
ever, understand  the  abnormal  without  having  first  obtained  more  or  less  clear 
conceptions  of  the  normal;  and  it  is  necessary,  therefore,  on  entering  upon  the 
study  of  tumors,  to  inquire  into  the  nature  of  the  law  which  is  violated  in  their 
growth,  even  though  we  may  not  hope  to  account  for  its  existence  or  explain 
the  method  on  which  it  acts.  We  may  do  this,  perhaps,  to  best  advantage  by 
considering  briefly  certain  facts  in  embryonal  and  post-embryonal  life. 

Every  animal  organism  begins  life  in  the  impregnated  egg.  From  this  cellu- 
lar unit  spring  an  enormous  number  of  cells,  whose  generation  takes  place  with 
a  predestined  order.  In  millions  of  individuals  of  the  same  species  there  comes 
almost  precisely  the  same  sequence  of  changes,  from  which  there  is,  only  in  rare 
cases,  any  deviation  whatever.  The  original  cell  divides  by  a  process  of  segmen- 
tation into  a  cluster  of  cells,  which  soon  proceed  to  arrange  themselves  in  layers, 
assum  etheir  proper  relations  to  each  other,  become  differentiated,  and  event- 
ually develop  into  various  tissues  and  organs  under  a  compulsion  the  nature  of 
which  is  absolutely  mysterious  and  inscrutable. 

On  studying  these  manifestations  of  Adtal  energy,  we  soon  come  to  see  that 
every  animal  organism  becomes  such  by  virtue  of  its  own  inherent  force.  In  it- 
self lies  the  power  which  compels  every  cell  within  its  limits  to  expend  its  en- 
ergies only  in  such  ways  as  will  contribute  to  the  general  good. 

The  environment  has  an  influence  on  the  development  and  growth  of  the  cell, 
for  it  affects  those  external  conditions  of  protection,  temperature,  nutrition,  etc., 

370 


THEORIES  OF  TUMOR  FORMATION.  371 

on  which  every  living  thing  is  dependent;  but  it  has  no  power  to  initiate  the 
evolution  of  the  embryo  nor  to  keep  the  proliferating  cells  in  proper  control. 

To  a  complex  organism,  however,  the  existence  of  a  governing  power  within 
itself  is  a  primal  necessity,  for  if  its  constituent  units  should  multiply  without 
regard  to  its  necessities,  if  it  could  neither  limit  their  propagation  nor  get  rid  of 
them  when  they  had  become  useless,  it  would  necessarily  die  from  its  own  weak- 
ness. Accordingly  we  find  in  every  normal  animal  body  evidences  of  the  exist- 
ence of  just  such  a  controlling  force,  and,  if  we  study  carefully  the  changes  which 
occur  in  the  growing  embryo  and  in  the  nutritive  processes  of  the  adult,  we  may 
distinguish  two  modes  of  action  by  means  of  which  it  produces  the  necessary  re- 
sults. By  the  one  it  forms  continually  new  cells  and  tissues  and  sometimes  new 
organs,  while  it  removes  by  the  other  all  debris,  destroys  all  cells,  tissues,  and 
organs  which  have  accomplished  their  end  and  become  effete,  and  causes  the 
disintegration  and  absorption  of  all  living  matter  which  has  become  useless  or 
obstructive.  There  is  nothing  more  wonderful  in  nature  than  the  working  of 
this  imseen  and  unobtrusive  force.  We  see  in  the  embryo  masses  of  cells  form 
themselves  into  organs,  which  perform  some  obscure  function  and  then  disap- 
pear. The  Wolffian  body  has  for  the  most  part  diminished  to  nothing  at  the 
close  of  the  sixteenth  week  of  gestation,  but  one  portion,  that  destined  to  form 
the  sexual  organs,  has  increased  in  size  and  importance.  In  the  formation  of  the 
vagina  we  see  the  same  processes  of  tissue  building  and  tissue  destruction  going 
on  simultaneously,  the  Mueller's  ducts  coalescing  in  the  middle  line  and  the  cen- 
tral cells  disintegrating  and  disappearing.  If  we  watch  the  growth  of  bones,  we 
find  taking  place  together  a  growth  of  bone  and  a  destruction  of  cartilage. 
Everywhere  we  see  the  exercise  of  a  controlling  power  which  compels  all  cellular 
action  to  proceed  on  certain  defined  lines. 

We  may  say,  in  a  certain  sense,  that  Nature  abhors  a  cellular  anarchy. 
Sometimes  she  is  betrayed  in  the  processes  of  evolution  into  an  excess  of  en- 
ergy, and  more  germinal  material  is  formed  than  can  be  utilized;  but  she  will 
then  try  to  regain  her  normal  standpoint  by  the  destruction  and  removal  of  the 
superfluous  mass.  A  notable  example  of  this  tendency  may  frequently  be  seen 
in  cases  where  extra  fingers  and  toes  are  found  on  newborn  children.  In  many 
cases  the  useless  members  are  well  formed,  but  so  located  as  to  be  of  no  use  to 
the  organism.  The  effort  to  remove  them  may  be  noted  in  the  absorption  of  the 
tissue  which  connects  them  to  the  extremity,  for  in  the  majority  of  instances 
they  hang  to  the  hand  or  foot  by  a  mere  thread  of  skin.  We  see  similar  evi- 
dences of  a  governing  power  in  adult  life,  where  there  is  constant  loss  of  organic 
units  which  must  be  met  by  a  corresponding  regeneration.  The  useless  and  ef- 
fete cells  are  destroyed  and  new  ones  appear  to  perform  their  functions.  Large 
organs  even  may  be  formed  to  replace  defects  produced  by  disease  or  injury,  as 
when,  after  removal  of  the  thyroid,  the  subsidiary  thyroids  which  exist  in  some 
persons  develop  into  large  and  active  glands,  or  as  when  a  kidney  doubles  in  size 


372  AMERICAN  PRACTICE  OF  SURGERY. 

to  compensate  for  the  loss  of  its  neighbor.  The  processes  by  which  these  results 
are  obtained  are  never  obtrusive  in  normal  conditions,  and  may  often  be  best 
studied  when  the  vital  operations  are  accentuated  by  disease  or  when  in  wounds 
they  are  exposed  to  the  eye.  In  the  latter  case  we  may  see  manifest  evidences 
of  the  twofold  action :  First,  proliferation  of  cells ;  and,  second,  their  eventual 
destruction  or  disappearance ;  and,  in  addition  to  these,  the  exercise  of  an  inhib- 
iting force  which  limits  a  cellular  proliferation,  after  it  has  reached  its  proper  limit. 

In  a  deep  wound  we  may  see  granulations  forming  with  great  rapidity,  but 
with  this  enormous  cellular  growth  there  goes  a  contraction  of  the  new  tissue, 
which  lessens  the  area  of  the  wound  and  draws  its  walls  together.  Finally,  when 
the  granulations  have  reached  the  surface  they  cease  to  multiply  and  become 
passive,  and  give  place  to  a  new  kind  of  cellular  activity,  that  of  the  adjacent 
epidermis,  which  then  grows  over  the  wound  surface  and  gives  it  its  protecting 
mantle.  This  accomplished,  the  new  tissue  gradually  changes  into  a  hard,  dense 
scar,  with  the  disappearance  of  the  cells  whose  activity  produced  the  healing. 
Thiersch  imagined  that  this  subsidence  of  connective-tissue  formation  on  reach- 
ing the  level  of  the  skin  was  due  to  a  power  residing  in  the  local  tissues,  which 
enables  them  to  repel  the  encroachment  of  cells  of  a  different  kind  on  their  do- 
mains. This  idea  has  been  modified  in  various  ways,  especially  by  German 
authors.  All  of  them  recognize  local  influences  which  limit  the  germination  and 
growth  of  cells  by  opposing  to  the  cellular  activity  the  active  or  passive  resist- 
ance of  a  living  environment.  The  resistance  may  take  the  form  of  pressure,  or 
of  secretions  unfavorable  to  cellular  growth,  or  of  monopoly  of  nutriment.  Other 
authorities,  extending  this  idea  until  it  embraces  the  entire  organism,  imagine 
that  the  organic  solidarity  is  due  solely  to  a  balance  maintained  between  antag- 
onistic tissues. 

It  seems  to  me  more  reasonable  to  believe  that  behind  all  the  phenomena  of 
generation,  growth,  and  nutrition  there  exists  in  every  complex  organism  some 
unconscious  intelligence  which  directs  and  controls  the  vital  processes.  I  cannot 
conceive  how  any  balance  could  long  exist  between  constantly  changing  tissues 
and  organs  which  may  lose  their  powers  of  resistance  by  any  chance  disease  or 
injury,  unless  there  is  some  regulating  force  inherent  in  the  organism  as  a  whole. 
It  is  only  by  means  of  such  a  controlling  power  that  that  perfect  co-operation 
and  co-ordination  of  the  cells  of  an  organism  can  be  maintained  which  are  the 
very  essence  of  physiological  unity.  Upon  the  perfection  of  this  controlling 
force  depends  the  perfection  of  the  individual.  It  is  when  this  force  is  weakened 
or  lost  that  we  see  groups  of  cells  develop  into  those  useless  and  destructive 
masses  which  we  call  timiors. 

When  we  call  in  review  these  facts  of  organic  life,  the  question  inevitably 
arises  whether  any  tumor,  even  the  most  innocent,  can  be  regarded  as  a  mere 
local  affair.  If  the  power  of  control  is  normal,  no  tumor  can  grow;  if  lost  over 
any  portion  of  the  body,  this  loss  may  indicate  a  vital  defect. 


THEORIES  OF  TUMOR  FORMATION.  373 

Before  the  days  of  Virchow,  the  word  "constitutional"  was  used  to  designate 
certain  diseases  which  were  supposed  to  arise  from  morbid  conditions  of  the 
blood.  Since  the  advent  of  cellular  pathology  and  the  demonstration  that  all 
maladies  originate  in  perverted  cellular  action,  the  word  has  lost  all  meaning  to 
the  pathologist. 

As  regards  neoplasms,  the  expression  used  by  W.  Roger  Williams,  of  Bristol, 
England,  "  that  nobody  nowadays  thinks  of  wasting  his  time  in  discussing  the 
obsolete  riddle  as  to  whether  these  diseases  are  of  local  or  constitutional  origin," 
represents,  doubtless,  the  present  attitude  of  the  professional  mind;  and  yet, 
this  much  may  be  said  on  the  other  side,  that  no  riddle  is  obsolete  that  is  im- 
solved.  Pathological  societies  may  put  such  questions  on  the  shelf  as  imworthy 
of  attention,  but  they  will,  nevertheless,  reappear  for  discussion  until  the  human 
mind  has  found  a  satisfactory  solution.  We  may  not  say  that  tumors  or  cancers 
are  constitutional  in  the  old  sense  of  that  word,  but  when  we  are  confronted, 
again  and  again,  with  certain  phenomena  for  which  we  cannot  account,  we  are 
compelled  to  ask  ourselves  whether  the  local  manifestations  represent  the  whole 
morbid  action,  and  whether  preceding  that  local  affection  and  accompanying  it, 
there  may  not  be  some  unknown  quantity  of  far  greater  importance.  We  have 
to  ask  ourselves,  then,  what  is  the  nature  of  the  force  which  co-ordinates  all  nor- 
mal cellular  activity,  and  how  it  is  that  it  becomes  paralyzed  and  inert.  The 
growth  of  a  tumor  may  indicate  either  that  a  single  group  of  cells  have  become 
emancipated  from  the  general  control,  or,  on  the  other  hand,  that  the  power  of 
the  organism  as  a  whole  to  govern  its  constituent  units  has  become  impaired. 
In  the  first  case,  the  tumor  may  be  of  only  local  significance;  in  the  second,  we 
have  a  condition  that  involves  the  Avhole  body  in  a  common  danger.  The 
appearance,  then,  of  even  the  most  innocent  neoplasm  may  have  in  it  some- 
thing portentous. 

There  are  reasons  for  believing  that  this  constitutional  defect  acts  much  more 
frequently  as  a  cause  of  tumors  than  is  generally  believed.  There  are,  first  of 
all,  the  numerous  cases  of  heredity,  where  neoplasms  of  various  kinds  appear  in 
a  family  through  several  generations.  There  is  no  other  way  of  accounting  for 
these  cases  except  on  the  theory  that  such  families  labor  under  defects  of  devel- 
opment and  growth.  Then,  again,  there  are  those  cases  where  many  and  diverse 
tumors  appear  on  the  person  of  the  same  individual — cases  difficult  to  under- 
stand on  the  theory  of  local  origin.  The  fact  that  in  old  age,  when  the  vital 
forces  are  weakened,  tumors  become  common,  points  also  to  some  general  cause 
for  their  occurrence. 

The  most  unanswerable  argument  for  such  a  belief,  however,  may  be  found 
in  the  study  of  the  metastases  of  malignant  tumors.  A  melanotic  sarcoma  makes 
its  appearance  in  some  locality,  and  thence  infects  the  whole  system  by  sending 
its  cells  or  their  nuclei  through  the  blood-vessels  to  all  parts  of  the  body.  The 
cells  lodge  and  multiply,  and  a  secondary  tumor  is  evolved,  precisely  like  the 


374  AMERICAN  PRACTICE  OF  SURGERY. 

primarj'  growth  in  structure.    No  tissue  in  the  person  so  affected  can  withstand 
the  invasion,  and  in  the  course  of  a  few  months  the  patient  dies. 

In  this  history  we  see  two  violations  of  organic  law.  The  first  is  the  original 
growth  of  useless  cells  in  the  organism.  This,  however,  might  be  accounted  for 
on  the  theory  of  local  severance  of  that  group  of  cells  from  their  physiological 
connection.  The  second  is  the  repeated  and  successful  implantations  of  these 
morbid  cells  in  spots  all  over  the  body.  The  normal  organism  would  resist  the 
growth  of  such  intruders  and  destroy  them.  This,  in  fact,  is  what  occurs  in  ar- 
tificial implantations  of  such  growths  in  healthy  animals;  the  graft  either  dies 
at  once  or  undergoes  speedy  degeneration  and  disappears.  It  is  only  occasion- 
ally that  an  animal  can  be  found  which  is  susceptible  to  the  inoculation  of  a  true 
tumor,  even  from  one  of  its  own  species. 

While  auto-inoculation  of  such  growths  is  the  rule,  the  successful  implanta- 
tion of  such  cells,  in  individuals  other  than  the  patient,  almost  never  occurs. 
Surgeons  and  medical  students  may  bury  their  hands  in  such  neoplasms,  carry 
away  fragments  under  their  finger-nails,  and  rub  the  pulpy  mass  into  cuts  and 
crevices  of  the  skui,  without  ever  showing  the  slightest  symptom  of  the  disease. 

If  we  reason  at  all  about  the  pathology  of  malignant  tumors,  we  have  no 
other  choice  than  to  assume  that  from  the  very  beginning  of  such  a  disease 
there  is  a  loss  of  control  which  involves  the  whole  organism.  'Whether  we 
should  apply  the  word  "constitutional"  to  such  a  weakness  or  defect  is  another 
question. 

Cohnheim's  Theory. 

The  most  brilliant  hypothesis  regarding  the  origin  of  tumors  ever  advanced 
is  that  of  the  German  pathologist  Cohnheim.  Like  all  other  new  ideas,  how- 
ever, this  theory  was  an  almost  inevitable  consequence  of  certain  positive  ad- 
vances in  knowledge,  which  enabled  the  student  to  look  upon  his  subject  from  a 
novel  standpoint. 

With  the  advance  of  embryological  and  histological  science,  the  theory  had 
become  generally  accepted  that  the  three  blastodermic  layers  represented  perma- 
nent divisions  of  tissues.  It  was  believed  that  the  ectodermal  and  entodermal 
layers  would  give  rise  only  to  cells  of  an  epidermal  or  epithelial  type,  and  that 
the  mesodermal  layer  would  produce  only  cells  with  peculiar  characteristics  of 
connective  tissues.  It  was,  however,  a  continual  struggle  to  reconcile  this  theory 
with  the  fact  that  epithelial  structures  are  frequently  found  embedded  among 
the  muscles  and  fascia  in  the  form  of  dermoid  cysts,  that  cartilage  is  found  in  tu- 
mors of  the  parotid  gland,  mammary  glandular  tvmiors  in  the  ax-illa,  etc.  The 
question  continually  arose,  whether,  under  the  stimulus  of  morbid  conditions, 
there  might  not  occur  a  metaplasia  of  cellular  elements  which  would  entirely 
change  their  character. 

The  study  of  these  conditions  led  to  a  possible  solution  of  the  problem,  by  the 
hypothesis  of  displaced  or  wandering  germs.    It  was  suggested  that  during  the 


THEORIES  OF  TUMOR  FORMATION.  375 

period  of  embryonic  development,  in  the  many  changes  in  the  relations  of  tissues 
and  organs,  cells  might  occasionally  become  pushed  out  of  their  proper  place  and 
remain  attached  to  other  structures  in  abnormal  positions  and  environments. 
If  we  assume  that  such  cells  survive  their  uncongenial  surroundings,  overcome 
the  resistance  of  neighboring  structures,  and  multiply  and  grow  into  masses  of 
tissue,  we  have  a  plausible  explanation  of  heterologous  tumors.  The  enchon- 
droma  of  the  parotid  appears,  then,  as  a  growth  from  cells  which  have  been  de- 
tached, in  the  formative  stage  of  the  embryo,  from  the  germinal  substance  of  the 
ear  and  have  become  attached  to  the  parotid ;  the  adenoma  or  mammary  glandu- 
lar tumor  of  the  axilla  springs  evidently  from  detached  portions  of  the  nascent 
mammary  gland ;  the  dermoid  cysts  of  the  neck  have  originated  from  ectodermic 
cells  which  have  accidentally  been  turned  into  the  depths  during  the  coalescence 
of  the  branchial  arches.  In  this  last  instance  a  corroboration  of  the  theory  has 
been  obtained  from  the  history  of  those  cases  of  dermoid  cysts  in  the  fingers  of 
sewing-women,  which  are  caused  by  implantations  of  minute  portions  of  the 
epidermis  by  needle  punctures.  This  theory  of  displaced  germinal  matter  is  so 
plausible  and  explains  so  many  otherwise  inexplicable  pathological  conditions 
that  it  has  met  with  general  acceptance. 

Cohnheim,  however,  evolved  from  this  class  of  facts  a  theory  covering  the 
etiology  of  all  neoplasms.  He  assumed  that  in  most  healthy  animals  more 
germinal  matter  is  formed  during  the  evolution  of  the  embryo  than  can 
possibly  be  used  for  purposes  of  development,  and  that  these  superfluous 
cells  might  persist  indefinitely  in  the  organism  long  after  the  period  had 
passed  when ,  they  could  enter  into  physiological  relations  with  the  rest  of 
the  body.  He  supposed  that  such  redundant  germinal  matter  might  date 
from  any  period  of  embryonic  life,  from  the  earliest  period  after  impregnation 
to  the  full  completion  of  development,  retaining  in  its  latent  condition  the 
same  capacity  for  multiplication  as  that  possessed  by  embryonal  material  in 
the  same  stage  of  organization. 

Reasoning  by  analogy  from  the  normal  to  the  abnormal,  he  instanced  the 
life  history  of  the  uterus.  This  organ,  when  impregnated,  begins  to  grow,  form- 
ing new  muscular  tissue,  until  it  measures,  after  the  expulsion  of  the  foetus,  four 
or  five  times  its  original  volume.  It  then  undergoes  the  process  of  involution, 
when  the  superfluous  uterine  tissue  disappears,  leaving  the  organ  slightly  larger 
than  the  virgin  uterus.  This  sequence  of  events  occurs  in  every  successive  preg- 
nancy, the  growth  after  impregnation  being  followed  by  the  destruction  of  the 
new  tissue  after  childbirth.  Cohnheim  urges  that  there  is  only  one  explanation 
of  these  events  possible.  There  must  exist,  in  the  uterus,  germinal  matter  which 
responds  to  the  stimulus  of  pregnancy  and  then  develops  into  adult  tissue.  In 
every  pregnancy  some  of  this  store  of  embryonic  material  is  used  up,  and  finally 
the  supply,  after  repeated  pregnancies,  becomes  exhausted.  In  case  pregnancy 
should  not  occur,  these  germs,  responding  to  some  other  stimulus,  may  develop 


376  AMERICAN  PRACTICE  OF  SURGERY. 

abnormally  into  those  fibro-muscular  tumors  so  common  in  old  virgins  and  in 
barren  women. 

Like  the  supposititious  germs  of  the  uterus,  so,  too,  the  hypothetical  super- 
fluous germs,  left  stranded  in  the  tissues  after  the  wave  of  evolution  had  passed 
by,  might,  under  favorable  circumstances,  develop  later  in  life  into  tumors. 

If  they  were  pushed  out  of  the  vital  current  at  an  early  stage  of  development, 
before  the  cellular  masses  had  become  differentiated  into  tissues,  they  would  re- 
tain that  enormous  generative  energy  which  is  common  to  that  stage  of  life. 
Thence  would  originate  those  terrible  cellular  growths  which  we  class  together 
under  the  name  "sarcoma,"  or,  if  residual  from  the  ectoderm  or  entoderna,  the 
various  forms  of  cancer.  The  aggressive  powers  of  such  neoplasms  are  due,  ac- 
cording to  Cohnheim,  to  the  unexpended  embryonic  energy  bottled  up  in  such 
residual  cells. 

On  the  other  hand,  those  tumors  which  originate  from  germinal  matter  at  a 
later  period,  when  this  force  has  abated,  after  the  tissues  have  become  differen- 
tiated and  fixed,  would  partake  of  a  histoid  character  and  grow  more  slowly  and 
be  less  infectious. 

As  regards  the  development  of  such  germs  into  tumors,  two  factors  are  nec- 
essary: one  is  the  destruction  of  the  resisting  power  of  the  normal  tissues  in 
which  the  germs  are  embedded,  which  would  otherwise  inhibit  the  growth  of  the 
abnormal  cells;  and  the  other  is  the  application  of  some  stimulus  which  would 
arouse  the  latent  germinative  energy. 

While  this  theory  may  be  accepted  with  some  reserve  in  explanation  of  those 
congenital  heterologous  tumors  due  to  the  persistence  and  growth  of  displaced 
germinal  matter,  there  are  reasons  for  doubting  its  applicability  to  neoplasms  of 
a  different  character.  In  view  of  the  fact  that  one  of  the  positive  laws,  in  a  com- 
plex animal  organism,  is  that  which  determines  the  degeneration  and  ultimate 
destruction  of  all  tissues  which  have  neither  present  nor  potential  utility,  it 
is  difficult  to  believe  that  embryonic  germs,  subject  like  all  cellular  vmits  to  the 
action  of  this  law,  could  persist  for  years  together  in  a  hostile  environment, 
neither  disappearing  nor  enlarging  until  the  time  came  for  them  to  grow  into 
tumors.  It  seems  more  probable  that  adult  cells  may,  under  pathological  condi- 
tions, change  their  nature  and  undergo  a  degeneration  marked  by  great  activity 
in  the  production  of  a  low  grade  of  offspring.  Borst  raises  the  question  whether 
persistent  dislocated  germs  are  in  reality  more  disposed  to  the  heteroplastic  de- 
velopment than  others,  and  answers  the  question  in  the  negative.  Many  of  the 
examples  he  quotes,  however,  do  not  seem  to  me  altogether  pertinent.  Acces- 
sory thyroids  and  suprarenal  capsules,  even  though  out  of  normal  position, 
might,  if  able  to  perform  the  functions  of  those  glands,  have  a  perfect  physio- 
logical connection  with  the  organism.  As  regards  accessory  thyroids,  there  can, 
in  fact,  be  little  doubt  that  they  have  in  some  cases  of  loss  of  thyroid  saved  the 
patients  from  myxcedema.    Indeed,  it  has  been  stated  on  good  authority  that 


THEORIES  OF  TUMOR  FORMATION.  377 

patients  have  even  been  cured  of  cachexia  strumipriva  by  the  successful  implan- 
tation of  thyroid  tissue  in  the  abdomen. 

Borst  is,  however,  undoubtedly  right  when  he  asserts  that  neither  the  aber- 
ration nor  the  persistence  of  supernumerary  germs  suffices  in  itself  to  produce 
neoplastic  growths.  There  must,  in  addition,  be  added  an  unknown  element 
which  has  thus  far  escaped  all  analysis. 

We  may  say,  however,  of  this  theory  of  Cohnheim's  that  it  is  the  only  one 
advanced  since  the  days  of  humoral  pathology  which  has  even  attempted  to  ac- 
count in  a  comprehensive  and  rational  manner  for  the  occurrence  of  neoplasms. 
It  has  acted  as  a  wonderful  stimulus  to  the  whole  profession  in  their  studies  of 
this  dark  subject,  and,  if  it  has  not  solved  the  whole  riddle,  it  has,  nevertheless, 
thrown  great  light  on  many  of  the  questions  nvolved.  In  the  opinion  of  this 
great  pathologist  the  cells  from  which  tumors  arise  are  from  the  very  beginning 
abnormal. 

It  is  interesting  to  note  that  the  best  men  of  to-day  are  adopting  generally 
this  point  of  view.  They  differ,  however,  from  Oohnheim  in  this,  that  they  do 
not  regard  embryonal  aberration  and  persistence  as  the  only  abnormal  condi- 
tions which  are  capable  of  producing  the  result.  There  is  reason  to  think  that 
under  certain  unknown  conditions  adult  cells  may  undergo  metaplasia,  or,  if  you 
please,  an  anaplasia — a  process  of  degeneration  in  which  they  so  far  simulate  em- 
bryonic tissue  that  they  acquire  the  power  of  rapid  multiplication,  although,  un- 
like embryonal  material,  they  are  incapable  of  developing  differentiated  cells  of 
a  high  grade.  The  cell  progeny,  even  in  histoid  tumors,  is  badly  formed  and 
abnormal,  while  in  the  more  malignant  growths  it  represents  the  lowest  form  of 
undifferentiated  cells.  It  always  is  marked  by  an  absence  of  purpose  and  a 
uselessness,  which  are  the  most  certain  criteria  of  a  true  tumor.  Ribbert  derives 
the  beginning  of  a  tumor  from  the  disruption  of  the  physiological  relations  of  a 
cell  or  group  of  cells  to  the  organic  whole.  He  believes  that,  whatever  unknown 
forces  may  cause  the  disruption,  when  a  cellular  unit — either  in  embryonic  or  in 
post-uterine  life — undergoes  this  change,  it  thenceforward  leads  a  life  of  its  own, 
regardless  of  all  organic  laws.  He  denies  to  these  elements  the  power  of  produc- 
ing in  neighboring  cells  a  similar  metamorphosis,  but  asserts  positively  that  they 
grow  into  tumors  from  their  own  inherent  wild  energy,  by  the  multiplication  of 
their  own  cells,  pushing  tissues  aside  and  compressing  them,  or  forcing  their  way 
into  every  crevice,  and,  in  the  malignant  varieties,  destroying  the  component  cells. 

In  this  respect  Ribbert  differs  from  some  other  pathologists,  who  ascribe  to 
the  original  morbid  elements  a  quality  which  enables  them  to  cause  in  their  sister- 
cells,  by  mere  contact,  similar  morbid  tendencies.  In  their  view  the  tumor,  orig- 
inating in  some  great  disturbance  in  cellular  relations,  grows  by  constant  accre- 
tions from  without,  as  one  cell  after  another  yields  to  the  morbid  impulse. 

Max  Borst,  who  has  considered  the  subject  exhaustively  from  all  standpoints, 
concludes  that  the  causes  of  neoplasms  must  be  sought  in  the  internal  conditions 


378  AMERICAN  PRACTICE  OF  SURGERY.  _ 

of  the  tissues  in  which  they  originate.  He  assumes  the  existence,  in  every  case, 
of  some  congenital  pathological  quality  of  cells  or  tissues  as  the  foundation  for 
the  formation  of  a  neoplasm.  Among  the  anatomical  conditions  for  considera- 
tion in  this  connection  he  mentions,  first,  gross  disturbances  in  the  development 
of  a  region  or  organ  or  system;  second,  displacements  of  embryonal  germs  or 
disruption  of  such  germs  from  their  physiological  connections  without  displace- 
ment; third,  formations  of  superfluous  germs  in  foetal  life;  fourth,  abnormal 
persistence  of  tissues  which,  in  normal  course,  should  have  disappeared;  and, 
fifth,  failures  in  the  differentiation  of  cells  and  minute  disturbances  in  their  idio- 
plastic  development. 

Cheyne,  of  Edinburgh,  assuming  that  every  cell  carries  within  itself  a  male 
and  a  female  element,  fancies  that  a  disturbance  of  their  relations  may  account 
for  the  formation  of  tumors,  the  female  element  becoming  ungovernable  and  de- 
veloping without  physiological  purpose.  This  theory  lacks  that  foundation  on 
established  facts  which  alone  can  give  a  theory  recognition  by  scientists.  In  the 
most  of  these  theories  the  main  element  in  the  production  of  the  abnormal  growth 
is  sought  for  in  the  aggressive  action  of  the  tumor  cells,  but  some  authors  are  dis- 
posed to  lay  the  principal  stress  on  the  loss  of  resisting  power  in  neighboring  tis- 
sues. Thus  Thiersch  regards  the  atrophy  of  the  connective  tissues  in  old  age  as 
the  primary  cause  of  epithelioma,  the  epithelium  growing  wildly  and  irregularly 
because  it  is  no  longer  checked  by  the  conservative  resistance  of  the  tissue  under- 
neath. Regarding  the  organism  as  held  together  by  a  mutual  balance  and,  to 
some  extent,  by  antagonism  between  the  various  structures  and  organs,  he  con- 
ceives the  loss  of  that  balance  to  be  of  primary  importance  in  the  causation  of 
all  irregular  cellular  proliferation. 

In  all  of  these  theories  we  may  recognize  the  perception  on  the  part  of  pa- 
thologists that  there  is  something  monstrous  and  portentous  in  the  useless  and 
aimless  growth  of  cells  which  we  class  together  under  the  name  of  true  tumors 
or  neoplasms.  They  occupy  a  peculiar  and  unique  place  in  biology,  for  in  no 
other  class  of  vital  processes  can  we  witness  the  component  units  of  an  organism 
separating  themselves  from  the  organic  whole  and  fastening  themselves  upon  it 
as  parasites  and  enemies. 

The  criterions  on  which  we  base  our  diagnoses  of  true  tumors  are,  then,  the 
evidences  which  we  see  of  an  organic  rupture  which  endangers  the  very  life  and 
being  of  the  animal.  There  can  be  no  other  symptom  which  indicates  such  a 
profound  disturbance  of  a  complex  organism  as  the  wild  generation  of  useless 
cellular  masses.  In  this  common  feature  lies  the  mystery  of  all  tumors,  innocent 
and  malignant.  The  essential  nature  of  a  lipoma  or  fibroma  or  osteoma  is  closely 
allied  to  that  of  a  sarcoma  or  cancer.  The  same  law  is  broken  in  the  growth  of 
one  as  in  that  of  the  other,  and  whether  the  result  is  a  comparative  innocuous- 
ness  or  a  virulent  malignancy  would  seem  to  be  a  matter  of  degree  in  morbid 
action  rather  than  one  of  kind. 


THEORIES  OF  TUMOR  FORIIATIOX.  379 

Before  proceeding  to  the  consideration  of  those  theories  which  seek  to  explain 
the  phenomena  presented  by  tumors  and  cancers  by  the  action  of  microscopic 
parasites,  it  may  be  well  to  tm^n  our  attention  for  a  moment  to  the  pathology  of 
that  most  virulent  class  of  neoplasms  which  are  termed  par  excellence  malignant. 
If  we  study  the  natural  history  of  tumors  with  exclusive  attention  to  the  two 
ends  of  a  long  series,  we  may  divide  them  into  two  classes,  innocent  and  malig- 
nant, the  first  of  which — although  its  members  may  cause  damage  by  pressure 
or  weight  or  mechanical  interference  with  the  blood  supply  or  nerve  conduction 
— is  not  in  itself  dangerous  to  life,  while  the  second  is  primarily  and  always  viru- 
lent and  destructive.  If,  however,  we  take  a  more  general  view  of  the  subject, 
and,  instead  of  occupying  ourselves  solely  with  the  extremes  of  the  series,  exam- 
ine all  with  reference  to  their  action  upon  the  human  body,  we  become  convinced 
that  the  innocency  or  malignity  of  a  tumor  is  not  that  which,  biologically  speak- 
ing, is  its  most  marked  characteristic.  We  shall  find  that,  while  the  quality  of 
virulence  is  much  more  marked  in  some  tumors  than  in  others,  there  is  hardly 
any  kind  of  neoplasm  which  may  be  said  never  to  show  it  in  some  degree.  There 
are  many  tumors,  too,  considered  quite  innocent,  which  have  a  tendency  in  time 
to  change  their  characteristics  in  this  respect  and  become  malignant,  either  by  a 
metaplasia  of  tissue  or  by  offering  a  favorable  soil  for  the  growth  of  other  neo- 
plasms, ilalignancy  in  a  tumor  is  but  another  name  for  a  tendency  to  make 
metastases.  The  cells,  multiplying  rapidly,  cling  no  longer  to  their  original  hab- 
itat. Some  of  them  push  their  way  in  long  lines  which  may  be  traced,  in  epi- 
theliomas, from  the  surface  through  crevices  in  the  underlying  tissues  far  into 
the  depths;  others,  getting  into  the  lymphatic  spaces,  are  carried  through  the 
lymphatic  vessels  into  the  neighboring  lymphatic  nodes.  Thence  they  reach,  in 
time,  the  deeper  lymphatics,  and  finally  are  discharged  into  the  blood  current. 
Others,  again,  as  in  sarcomas,  involve  the  capillaries  and  veins  at  an  early  stage 
of  the  disorders,  fill  up  the  Imnen  of  these  vessels,  and  are  sooner  or  later  carried 
away  as  malignant  emboli  to  lodge  and  grow  in  some  distant  part  of  the  body. 
"Where  such  ttmiors  grow  into  the  intestines  or  urinary  passages,  detached  frag- 
ments may  pass  dowTi  with  the  excreta  and  become  implanted  lower  do'mi  in  the 
canals.  A^Tien  projecting  into  the  serous  cavities,  they  fall  to  the  lower  levels  and 
cause  numeroas  secondary  growths. 

Mrchow  long  since  pointed  out  the  conditions  which  favored  metastasis. 
They  are,  first,  a  tissue  formation  which  permits  the  easy  detachment  of  cells. 
In  histoid  tumors,  like  lipomas,  fibromas,  etc.,  the  cells  have  become  differenti-  • 
ated,  multiply  slowly,  and  have  firm  coimections  with  the  intercellular  sub- 
stance. Such  cells  are  torn  with  difl[iculty  away  from  their  attachments,  and 
metastases  of  such  tumors  are,  of  necessity,  rare,  and  occur  only  when  through 
some  metaplastic  change  they  have  become  more  cellular  and  when  the  bonds 
of  the  cells  to  the  stroma  have  become  less  rigid.  It  is  evident  that  the  drier  and 
firmer  tissues  are,  the  more  permanent  they  are  in  form.     For  this  reason  the 


380  AMERICAN  PRACTICE  OF  SURGERY. 

tendency  to  metastasis  increases  with  the  succulency  of  the  tissues.  The  greater 
the  amount  of  fluid  contained  in  a  tumor,  the  less  stable  are  its  component  ele- 
ments. The  size  and  shape  of  the  tumor  cell  also  have  an  influence  upon  its  ten- 
dency to  metastasis.  A  small  cell  can  more  readily  pass  through  a  narrow  channel 
than  a  larger  one,  and  a  round  or  spindle-shaped  cell  than  one  that  is  irregular 
or  angular.  More  potent,  however,  than  all  of  these  qualifications  for  malignant 
growth  is  the  possession  of  a  great  proliferating  energy.  Neither  loose  connec- 
tions, small  size,  nor  round  shape  could  endow  a  fat  cell  with  the  aggressive  force 
which  enables  a  cellular  unit  to  supplant  and  destroy  its  normal  neighbors. 
There  must  be  an  inherent  energy  such  as  we  see  manifested  in  normal  condi- 
tions only  by  embryonal  cells.  Whether  malignant  growths  spring  from  persist- 
ent embryonic  germs,  as  Cohnheim  affirms,  or  whether  there  is  a  reversion  of 
adult  cells  to  an  embryonal  form  and  condition,  as  some  assert,  or  whether, 
finally,  without  undergoing  that  kind  of  retrograde  change,  certain  adult  cells, 
when  their  physiological  bonds  are  broken,  may  acquire  the  power  of  generating 
great  quantities  of  a  low-grade  progeny,  are  questions  which  in  the  present  state 
of  biological  science  cannot  be  decided. 

As  regards  the  secondary  tumors,  it  must  be  remarked  that  they  invariably 
are  composed  of  the  same  type  of  cells  as  that  of  the  primary  growth.  The  sec- 
ondary tumors  of  a  squamous-celled  epithelioma  are  composed  of  squamous  cells, 
those  of  a  columnar-celled  cancer  have  columnar  cells,  and  the  metastatic  growths 
of  a  sarcoma  invariably  show  their  mesoblastic  origin  in  the  character  of  their 
cellular  elements. 

While  adhering  to  the  same  type  of  structure  as  that  exhibited  by  the  pri- 
mary growth,  the  metastatic  tumors  may,  nevertheless,  deviate  from  it  in  some 
particulars.  The  secondary  and  tertiary  tumors  will  sometimes  be  more  sviccu- 
lent  than  the  primary  and  hasten  more  rapidly  the  disintegration,  but,  while  the 
cells  of  such  tumors  undergo  a  metaplasia  to  a  lower  grade  of  development,  they 
do  not  lose  their  distinctive  equalities. 

The  course  followed  by  malignant  growths  in  their  dissemination  throughout 
the  system  is  so  similar  to  that  pursued  in  infections  of  various  kinds  in  which 
the  active  agent  is  a  microscopic  parasite  that  many  pathologists  have  come  to 
regard  them  as  diseases  of  allied  nature.  Long  before  the  days  of  cellular 
pathology,  men  were  disposed  to  look  upon  cancers  as  parasites  on  the  human 
body,  and,  while  the  grosser  conceptions  of  a  hundred  years  ago  have  been 
discarded,  the  belief  has  lingered  in  the  human  imagination.  Of  late 
years  this  view,  modified  to  meet  the  present  conditions  of  science,  has 
been  pressed  upon  the  profession  by  many  enthusiastic  advocates  who  never 
tire  in  citing  the  various  points  in  which  cancer  and  sarcoma  resemble  the 
infectious  granulomas. 

In  all  these  maladies  the  disease  has  a  local  origin ;  in  all  it  spreads  through 
the  body  by  the  same  channels ;   in  all  it  generates  new  foci  in  continuous  and 


THEORIES  OF  TUMOR  FORMATION.  381 

contiguous  tissues;  in  all  the  active  agents  which  carry  the  disease  to  distant 
parts  of  the  body  are  carried  to  their  destination  in  the  lymph  and  blood  currents. 

San  Felice,  Roncali,  Plimmer,  and  other  scientists  in  Europe,  and  in  this 
country  Gaylord,  have  found  in  microscopical  sections  of  cancerous  tumors  pe- 
culiar figures  which  seemed  to  them  to  be  different  from  all  cells  found  in  the 
normal  tissues  of  the  human  body,  and  also  from  any  form  of  cell  degeneration 
known  to  the  pathologist.  They  affirm  that  they  have  been  able  to  grow  these 
so-called  Plimmer's  bodies  in  cultures  and  to  have  caused  fatal  growths  in  the 
lower  animals  which  have  been  inoculated  with  the  germs.  Plimmer  regards 
these  bodies  as  probably  saccharomycetes,  and  is  confident  that  they  are  the 
parasitic  organisms  which  are  responsible  for  the  occurrence  of  cancerous  tumors. 
These  views,  however,  have  not  met  with  general  acceptance.  There  is  one  point 
especially  which  distinguishes  malignant  growths  of  all  kinds  from  those  tume- 
factions which  are  caused  by  microbic  infection.  In  the  infectious  granuloma 
the  organism  which  conveys  the  infection  is  always  and  invariably  the  patho- 
genic microbe.  The  human  tissue  which  nature  builds  around  the  focus  of  in- 
fection to  wall  it  in,  and  if  possible  to  destroy  the  infectious  germs,  is  a  granula- 
tion tissue.  It  is  not  a  true  tumor,  but  a  false  tumor,  and  the  newly  formed  tissue 
is  built  up  by  the  organism  in  its  own  interests  as  a  defence  against  the  invasion. 
Of  widely  different  character  is  the  pathology  of  a  true  tumor.  In  the  human 
subject  it  springs  from  human  cells  which  in  some  mysterious  way  have  lost  their 
physiological  connections.  From  the  multiplication  of  these  cells  arise  the  pri- 
mary and  all  of  the  secondary  tumors.  If  metastases  are  formed,  it  is  because 
cells  or  their  nuclei,  which  have  been  separated  from  the  original  growth,  have 
floated  away  in  the  lymph  or  blood  channels,  have  lodged  elsewhere  in  the  body, 
and  have  generated  here  and  there  a  numerous  progeny  which  compose  new 
tumors.  This  new  tissue  is  not  formed  in  the  interests  of  the  organism,  to  pro- 
tect it,  but  is  itself  the  invader.  It  always  shows  in  the  character  of  its  cells  a 
likeness  to  the  cells  from  which  it  is  derived.  When  we  study  these  conditions 
with  reference  to  a  possible  parasitism  as  the  causal  factor,  we  have  to  ask  our- 
selves whether  it  is  possible  for  any  parasite,  animal  or  vegetable,  so  to  act  upon 
the  human  tissues  as  to  break  up  their  physiological  bonds  and  cause  their  cellu- 
lar units  to  grow  into  tumors,  and,  wandering  from  their  primary  seat,  to  estab- 
lish colonies  of  the  same  kind  in  various  parts  of  the  body. 

The  burden  of  proof  of  a  proposition  of  this  kind,  which  is  opposed  to  all  of 
our  experience,  rests  with  those  who  advance  the  theory ;  but  as  yet  it  has  not, 
in  one  single  instance,  been  demonstrated.  There  are  other  considerations,  too, 
which  apply  with  almost  equal  force  against  this  hypothesis.  There  is  a  rela- 
tionship between  tumors  of  all  kinds  which  cannot  be  ignored.  Malignancy  is 
not  confined  to  cancer  or  sarcoma,  but  is  an  attribute  of  many  and  various  kinds 
of  tumors.  In  our  studies  we  may  not  limit  our  researches  to  cancer  and  our  finds 
to  Plimmer's  bodies,  but  we  must  study  the  problem  of  malignancy  wherever  we 


382  AMERICAN  PRACTICE  OF  SURGERY. 

find  it.  If  it  is  the  result  of  parasitic  infection,  we  have  to  ask  whether  this  pe- 
culiar power  over  animal  cells  is  limited  to  .one  kind  of  parasite  or  is  common  to 
many;  whether  the  same  protozoa  or  blastomycetse  which  produce  cancer  also 
cause  the  phenomena  of  adenoma,  malignant  enchondroma,  sarcoma,  and  other 
neoplasms  with  malign  tendencies.  It  is  evident  that,  if  this  were  so,  every 
malignant  tiunor  would  be  a  mixed  tumor;  for  the  parasites  which  attacked  the 
epithelium  would  inevitably  come  in  contact  with  other  tissues,  and,  as  the  dis- 
ease progressed,  with  all  kinds  of  tissue.  The  lodgment  of  the  parasite  in  the 
mammary  ducts,  for  example,  would  first  affect  the  epithelium  and  connective 
tissues  of  the  breast ;  after  that,  as  the  disease  progressed,  the  underlying  mus- 
cles, and  then  the  cartilages  and  bones,  all  of  the  various  cells  of  these  tissues 
being  stimulated  to  a  malignant  and  prolific  generation  of  their  own  kind  of 
cellular  units.    It  is  evident  that  this  hypothesis  could  not  bear  criticism. 

On  the  other  hand,  there  are  difficulties  in  assummg  the  existence  of  a  lai-ge 
variety  of  parasitic  forms  each  of  which  is  gifted  with  the  power  of  causing  a 
wild  cell  proliferation  in  some  particular  tissue  for  which  it  has  a  predilection. 
As  the  matter  stands  to-day,  the  theory  of  a  causal  parasitic  infection  in  the  eti- 
ology of  tumors  has  not  been  sustained.  The  results  of  inoculations  with  Plim- 
mer's  bodies  have  not  been  convincing,  and  all  other  phenomena  which  are 
relied  on  to  sustain  the  hypothesis  can  be  better  explained  on  other  grounds. 

One  of  the  most  original  of  the  theories  in  support  of  the  doctrine  of  para- 
sitism is  that  advanced  by  Kelling,  of  Dresden.  It  occurred  to  this  author  that 
the  existence  of  cancer  might  be  explained  by  the  invasion  of  the  human  body  by 
embryonal  cells  derived  from  other  than  human  sources,  and  that  these  cells, 
more  or  less  altered  in  character  by  their  environment,  might  be  the  progenitors 
of  the  cancer  cells.  Having  a  foreign  origin,  they  could  not  enter  into  physio- 
logical relations  with  the  organism,  but  would  multiply,  grow,  and  destroy  after 
the  manner  of  parasites.  He  fancied  that  such  cells  might  get  into  the  human 
tissues  from  various  sources,  as,  for  instance,  from  embryonal  tissues  of  pigs, 
lambs,  fish,  snails,  etc. ;  but  that  the  most  frequent  cause  of  trouble  was  due  to 
the  ingestion  of  raw  impregnated  hens'  eggs  which  are  used  so  commonly  as 
food,  the  living  cells  obtaining  entrance  into  the  human  tissues  through  some 
crevice  or  some  ulcer  in  the  alimentary  canal.  He  examined  many  carcinomas 
from  human  subjects  biochemically,  in  order  to  determine  the  nature  of  the 
contained  albumin,  and  obtained  reactions  which  indicated  the  presence  of  the 
albimiin  peculiar  to  fowls  in  about  one-third  of  the  cases.  He  chose  for  these 
investigations  patients  with  gastric  cancer  secondary  to  gastric  ulcer,  who  had, 
on  account  of  the  last-named  disease,  been  fed  with  raw  eggs.  As  a  further  test, 
he  injected  embryonal  material  from  animals  into  animals  of  a  different  species, 
and  produced  thereby  tumors  which  eventually  caused  death.  He  regards  these 
tumefactions  as  true  tumors  of  a  malignant  type.  He  further  advances  the  opin- 
ion that  the  profession  may  hope,  from  the  development  of  these  biochemi- 


THEORIES  OF  TUMOR  FORMATION.  383 

cal  examinations,  to  obtain  a  new  and  trustworthy  method  of  diagnosticating 
cancer. 

His  ingenious  tlieory  and  tlie  conclusions  whicli  lie  draws  from  his  experi- 
ments have  not  been  considered  by  pathological  experts  as  warranted  by  the 
facts.  Like  all  hypotheses  which  would  explain  the  origin  of  tumors  on  a  basis 
of  parasitism,  this  of  Kelling  meets  with  an  insurmountable  obstacle,  in  the  his- 
togenetic  relations  of  all  tumors  and  cancers.  The  cells  of  all  tumors  and  their 
metastatic  progeny  are  of  the  same  type  as  the  tissues  from  which  the  primary 
growth  took  its  origin.  The  cells  in  human  cancers  could  never,  as  Ribbert  as- 
serts, have  arisen  from  the  cells  of  a  hen.  Ribbert,  whose  pre-eminence  in  histo- 
logical work  no  one  can  gainsay,  denies  positively  the  cancerous  nature  of  the 
growths  produced  by  Kelling's  experiments,  and  regards  them  as  enlargements 
due  to  irritation.  From  the  biochemical  side  Kelling  has  been  equally  unfor- 
tunate, the  investigation  which  Fuld  conducted,  with  the  purpose  of  obtaining 
the  reactions  of  hen  albumin  from  human  carcinomas,  having  yielded  only  nega- 
tive results. 

Among  the  theories  relating  to  the  origin  of  tumors  there  remains  yet  to  be 
mentioned  one  which  is  not  new  and  which  has  not  met  with  many  advocates. 
The  theory  that  tumors  might  be  due  to  nervous  disturbances  was  broached  by 
Schroeder  van  der  Kolk  in  the  middle  of  the  last  century.  There  seemed  at  that 
time  few  facts  to  support  it.  Since  then  the  study  of  acromegaly,  in  which  dis- 
ease enlargement  of  the  bones  has  been  associated  with  disease  of  the  pituitary 
body,  has  given  warrant  for  the  hypothesis  that  there  may  be  nervous  centres 
whose  function  it  is  to  regulate  growths. 

Recklinghausen  has  shown  that  the  spots  of  pigment  which  are  often  in  num- 
bers on  the  body,  appear  at  the  ends  of  nerves  and  are  associated  with  very  mi- 
nute fibromas.  Not  infrequently  cancers  and  sarcomas  develop  from  these  spots. 
It  would  seem  that  the  relations  of  the  nervous  system  to  tumors  of  all  kinds 
might  deserve  a  thorough  and  minute  investigation.  Should  it  ever  be  demon- 
strated that  cellular  generation  and  growth  depend  upon  some  as  yet  unknown 
nervous  centre,  the  inference  that  the  occurrence  of  tupiors  might  be  due  to  de- 
fects or  diseases  of  that  centre  would  not  be  unreasonable.  It  is  not  impossible 
that  even  before  any  nervous  system  comes  into  being  the  development  of  the 
embryo  may  be  regulated  by  certain  governing  cells.  If  such  hypotheses  seem 
like  idle  speculations,  it  must  be  remembered  that  the  solution  of  the  problem, 
if  it  ever  takes  place,  must  come  through  the  careful  and  patient  investigation 
of  every  suggestion  which  may  have  in  it  a  possibility  of  success. 

There  are  many  questions  which  arise  with  reference  to  neoplasms,  which 
admit  of  answer  only  on  a  basis  of  accurate  statistics.  This  phase  of  the  tumor 
question  has  come  recently  into  prominence  through  the  intense  interest  excited 
by  the  statements  of  certain  authors  to  the  effect  that  cancer  is  greatly  on  the 
increase.    The  importance  of  establishing  the  truth  or  error  of  this  opinion  can 


384  AMERICAN  PRACTICE  OF  SURGERY. 

be  hardly  overestimated,  and  it  is  well,  therefore,  to  ask  whether  there  are  any 
statistics,  covering  three  or  four  decades,  sufficiently  trustworthy  to  warrant 
such  a  positive  expression.  The  reliability  of  medical  statistics  depends  upon 
the  competency  of  the  great  mass  of  physicians  who  make  the  diagnoses  and 
furnish  the  death  certificates.  It  is  evident  that,  as  in  every  profession  there  are 
great  numbers  of  badly  educated,  stupid,  and  indifferent  men,  there  never  can 
be  any  medical  statistics  which  are  absolutely  exact.  The  utmost  that  can  be 
hoped  for,  under  the  most  favorable  circumstances,  is  the  attainment  of  results 
which  are  approximately  correct.  This  consideration  should,  of  itself,  inspire 
caution  in  accepting  any  very  positive  statements  based  upon  statistical  reports. 
When,  however,  as  in  the  case  of  the  relative  prevalence  of  cancer  in  different 
decades,  the  statistics  have  been  compiled  under  constantly  varying  conditions, 
the  profession  should  subject  such  statements  to  the  severest  criticism. 

There  has  never  been  a  period  in  the  history  of  medicine  when  such  radical 
changes  have  been  effected  as  in  the  last  forty  years.  During  that  period  of  time 
the  profession  has  abandoned  the  old  humoral  theories  of  disease  and  has  sub- 
scribed to  the  doctrines  of  cellular  pathology.  In  surgery  Lister's  discoveries 
have  caused  a  revolution  in  ideas  and  practice  which  can  be  described  only  as 
tremendous.  Preventive  medicine  has  become  a  science  in  itself,  and  health 
boards  have  been  established  all  over  the  civilized  world  as  permanent  additions 
to  the  social  organizations.  In  fact,  the  whole  situation  has  so  altered  that  the 
perusal  of  a  medical  book  written  before  1860  is  like  reading  a  work  of  Hippoc- 
rates or  Galen.  The  profession,  responding  to  the  stimulus  of  the  new  ideas, 
has  grown  in  stature.  Its  members  have  never  before  been  so  generally  enthusi- 
astic, and  have  never  in  the  same  lapse  of  time  made  advances  in  so  many  direc- 
tions. The  changes  have  taken  place  so  rapidly  that  no  two  decades  show  pre- 
cisely the  same  point  of  view  on  any  medical  subject.  The  doctrines  relative  to 
malignant  diseases  especially  have  been  revolutionized,  and  the  pessimism  of 
the  old  humoral  pathology  has  given  place  to  hopes  based  on  the  theory  of  local 
origin,  and  the  bias  of  the  profession  toward  these  diseases  has  become  reversed. 
The  general  practitioner  who  formerly  admitted  with  reluctance  the  existence  of 
cancer  when  it  was  beyond  hope  is  now  disposed  to  regard  every  obscure  malady 
as  possibly  malignant  and  to  recommend  operative  procedures  as  a  cure.  The 
laity,  participating  in  the  confidence  of  the  profession,  are  even  too  eager  to  seek 
in  surgery  a  remedy  for  every  ill.  The  operations  on  the  abdomen  have  disclosed 
new  pathological  conditions  and  made  clear  what  was  dubious  and  uncertain. 
It  was  inevitable  that  these  changes  should  become  reflected  in  the  health  re- 
ports, and  that  the  general  advance  in  intelligence,  in  insight,  and  in  efficiency 
should  manifest  itself  in  more  accurate  diagnoses.  These  changes  in  the  patho- 
logical conceptions  and  in  the  methods  of  diagnosis  and  treatment,  so  widely 
adopted  by  the  profession,  are  of  themselves  sufficient  to  account  for  an  appar- 
ent increase  in  cancer,  as  shown  by  the  health  reports  of  a  few  cities ;   but,  in 


THEORIES  OF  TUMOR  FORMATION.  385 

addition,  we  have  to  recognize  tlie  existence  of  other  factors  which  also  influence 
the  character  of  statistical  reports.  One  of  these  is  the  greater  efficiency  of  the 
health  boards  of  later  over  those  of  the  earlier  years.  This  is  especially 
noticeable  in  some  of  the  German  reports.  It  is  not  many  years  since  that  the 
records  of  deaths  in  most  civilized  countries  were  kept  in  the  most  slovenly 
and  careless  manner.  Even  now  the  methods  in  vogue  in  many  places  are  not 
beyond  improvement.  In  Wuertemberg,  for  instance,  according  to  Weinberg 
and  Caspar,  in  1899,  thirty-eight  per  cent  of  all  deaths  had  occurred  without 
the  attendance  of  qualified  practitioners.  Of  the  deaths  in  Stuttgart,  in  1879, 
thirty  per  cent  of  the  deaths  of  men  and  twenty-seven  per  cent  of  those  of  women 
had  taken  place  without  competent  medical  attendance,  but  in  1901  this  per- 
centage had  diminished  to  sixteen  per  cent  of  men  and  fifteen  per  cent  of  women. 

Another  element  to  be  considered  in  estimating  the  character  of  the  death 
certificates  of  the  various  decades  is  the  increasing  tendency  of  patients  suffer- 
ing from  surgical  maladies  to  seek  relief  in  the  hospitals;  and  still  another  is 
noticed  by  German  authorities  in  the  greater  relative  number  of  physicians  at 
the  present  time — a  change  which  has  insured  to  the  poorer  patients  more  thor- 
ough examinations  and  more  careful  diagnoses. 

After  examining  very  carefully  all  the  literature  which  I  have  been  able  to 
get  bearing  on  this  subject,  I  have  come  to  the  conviction  that  we  have  as  yet  no 
trustworthy  statistics  on  which  the  most  painstaking  investigator  could  base  a 
just  opinion  as  to  the  relative  prevalence  of  cancer  in  the  last  three  decades. 
The  same  criticism  may  be  made  about  other  very  positively  expressed  opinions. 
Statements  have  been  made  as  to  the  relative  prevalence  of  cancer  in  hot  and 
cold  countries,  among  savage  and  civilized  peoples,  among  meat-eaters  and  vege- 
tarians, and  on  certain  geological  formations,  which  statements  cannot  be  sup- 
ported by  anything  like  scientific  testimony.  The  inherent  difficulties  in  the  way 
of  getting  correct  data  on  a  large  scale  in  regard  to  tumors  are  so  great  that  we 
cannot  accept  without  scrutiny  any  statements  which  are  based  on  doubtful 
statistics,  or  on  the  impressions  of  travellers,  or  even  of  surgeons  in  large  prac- 
tice. These  difficulties  may  never  be  altogether  overcome,  but  it  may  be  pos- 
sible, by  getting  the  profession  sufficiently  interested,  so  to  lessen  the  causes  of 
failure  as  to  get  approximately  correct  results.  Until  that  is  accomplished  we 
must  be  content  to  suspend  our  judgment  on  many  questions.  What  we  ur- 
gently need  at  the  present  time  is,  not  hasty  generalizations  from  limited  experi- 
ences, but  correct  information,  carefully  and  systematically  acquired,  as  to  the 
conditions  which  influence  tumor  growth. 

A  review  of  the  numerous  hypotheses  and  theories  which  have  been  advanced 
to  account  for  the  existence  of  tumors  does  not  inspire  the  student  with  the  feel- 
ing that  the  problem  is  near  solution.  Those  which  seem  most  rational,  like 
Cohnheim's,  and  Ribbert's  modification  of  Cohnheim's,  impress  one  rather  as 
exaggerated  statements  of  certain  facts  than  as  serious  attempts  to  explain  them. 
VOL.  I. — 25 


386  AMERICAN  PRACTICE  OF  SURGERY. 

There  can  be  little  doubt  that  there  are  certain  defects  in  development  which 
are  characterized  by  the  formation  of  superfluous  cells ;  that  in  some  cases  these 
cells  suffer  displacement ;  and  that  in  some  they  persist  and  develop  abnormally 
in  intra-uterine  or  post-uterine  life.  The  riddle  is  not  solved  by  these  state- 
ments, but  is  differently  presented.  We  have  still  to  learn  the  natvire  of  that 
physiological  bond  which  makes  the  existence  of  complex  organisms  possible — the 
bond  which  is  broken  whenever  and  wherever  a  tumor  exists. 


PARASITICAL  RELATIONS  OF  CAKCER. 

By  HARVEY  R.  GAYLORD,  M.D.,  Buffalo,  N.  Y. 


The  belief  that  the  cancerous  process  is  due  to  some  parasite  has  come  down 
to  us  with  our  earhest  knowledge  of  this  affection.  In  the  minds  of  the  earlier 
observers  this  was  due  to  the  frequent  confusion  of  cancer  and  certain  of  the  in- 
fectious granulomata,  especiallj'  tuberculosis.  The  clinical  course  of  many  of  the 
sarcomata  and  the  difficulty  frequently  met  with  in  distinguishing  sarcoma  in  its 
clinical  aspect  from  such  processes  as  Hodgkin's  disease,  which  is  undoubtedly 
infectious,  have  sufficed  to  keep  alive,  in  the  minds  of  many  clinicians,  the  belief 
in  the  infectious  nature  of  the  malignant  processes.  It  is  obvious  that  a  purely 
clinical  point  of  view  may  be  one-sided,  but  there  is  little  doubt  that  manj'  of  the 
theories  which  have  been  advanced  by  pathology  have  not  sufficiently  considered 
the  clinical  aspects  of  the  disease  or  else  have  ignored  them  entirely.  The  major- 
ity of  pathologists  are  at  present  distinctly  opposed  to  the  belief  that  any  parasite 
exists  which  could  fulfil  the  role  of  a  parasite  for  cancer.  It  is  obvious  that  no 
ordinary  parasite  could  fulfil  this  role.  Therefore,  when,  in  1886,  Scheuerlin, 
and  later  Schill,  detected  bacteria  in  cancer,  it  was  not  long  before  these  organ- 
isms were  found  to  be  simply  harmless  saprophytes.  This  also  may  be  stated  to 
have  been  the  case  with  the  yeast  organisms  or  blastomycetes,  which  have  been 
more  recently  described  by  San  Felice  and  others  as  occurring  in  carcinomata. 

INCLUSIONS  IN  CANCER. 

Since  the  earliest  histological  investigations  of  cancer,  there  have  been  ob- 
served in  the  cells  certain  objects,  as  to  the  significance  of  which  much  discussion 
has  taken  place.  It  is  not  profitable  to  consider  here  the  question  whether  or 
not  these  bodies  are  parasites.  It  is  interesting  to  note,  however,  that  as  early  as 
1847  Virchow  described  these  objects,  believing  them  to  be  metamorphosed  nuclei 
or  degenerative  changes,  of  a  fatty  character,  in  the  protoplasm  of  the  cancer  cells. 
They  were  again  described  in  1889  by  Thoma,  who  believed  that  they  were  proto- 
zoa ;  in  1890  by  Sjobring  and  Siegenbeck  van  Heukelom ;  in  1891  by  Steinhaus ;  in 
1892  by  Soudakewitsch,  Borrel,  Foa,  Kursteiner,  Podwyssozki,  and  Sawtschenko; 

387 


388  AIMERICAN  PRACTICE  OF  SURGERY. 

in  1893  by  Ruffer  and  Walker  and  Ruffer  and  Plimmer;  in  1894  by  J.  Jackson 
Clarke  and  Cattle;  in  1896  by  Pianese;  in  1898  by  Bosc;  in  1901  by  E.  van  Ley- 
den  and  Gaylord;  in  1902  by  Feinberg,  Greenough,  Nosske,  and  Posner;  in  1903 
by  Apolant  and  Embden;  and  in  1904  bj^  G.  N.  Calkins.  Of  these  observers, 
Pianese,  Greenough,  Nosske,  and  Apolant  and  Embden  believed  that  the  bodies 
in  question  are  not  parasites.  The  others  held  them  to  be  protozoa  or  allied  or- 
ganisms. Calkins  holds  that,  although  they  have  not  been  proven  to  be  so,  they 
may  nevertheless  be  parasites.  The  forms  in  question  have  come  to  be  known  as 
"Plimmer's  bodies,"  or  Van  Leyden's  "bird's-eye  inclusions,"  or  the  "x-bodies" 
of  Behla.  They  are  spherical  structures,  which  var}^  in  size  from  four  to  forty 
microns.  They  have  a  delicate  limiting  membrane  and  a  central,  highly  refrac- 
tive body.  The  space  between  the  central  body  and  the  margin  sometimes  con- 
tains a  fine  protoplasmic  structure,  while  at  other  times  granules  are  regularly 
distributed  between  the  periphery  and  the  central  bod3\  They  have  been  ob- 
ser\^ed  in  the  nucleus  and  in  the  protoplasm,  and  in  the  intranuclear  forms  they 
present  an  appearance  not  unlike  the  similar  inclusions  which  have  been 
observed  in  smallpox  and  in  vaccinia.  These  bodies  have  been  seen  in  the  fresh 
state,  but  thej^  are  best  demonstrated  by  complicated  hardening  and  staining 
methods. 

There  is  no  direct  proof  that  these  bodies  are  parasites,  although  many  ob- 
servers have  maintained  the  belief  that  they  are  such.  On  the  other  hand,  those 
who  have  attempted  to  show  that  they  are  not  parasites  have  been  forced  to 
employ  the  same  methods  of  reasoning,  and  it  can  be  fairly  stated  that  to-day 
neither  those  who  hold  that  they  are  of  a  parasitic  nature  nor  those  who  hold 
that  they  are  not,  are  in  a  position  to  prove  their  contention.  The  preponder- 
ance of  opinion  is  opposed  to  the  view  that  these  bodies  are  of  a  parasitic  nature, 
but  this  is,  to  no  inconsiderable  extent,  due  to  the  fact  that  the  majority  of  pa- 
thologists hold,  on  a  priori  grounds,  that  cancer  is  under  no  circumstances  an 
infectious  process.  There  are  some  observers,  however — notably  Borrel — who 
hold  that  cancer  is  an  infectious  process,  that  these  inclusions  are  not  parasites, 
but  that  there  is  an  infective  agent  in  cancer  which  is  either  undemonstrable  or 
ultra-microscopic.  Perhaps  the  best  arguments  in  favor  of  the  inclusions  being 
parasites  are  these:  Their  similarity  in  appearance  to  a  known  organism — 
Plasmodiophora  brassicse — and  the  fact  that  in  certain  respects  they  resemble 
certain  forms  of  the  smallpox  organism. 

CANCER  AND   THE   ACUTE   EXANTHEMATA. 

Although  at  first  thought  there  would  scarcely  appear  to  be  any  relation 
between  the  cancerous  process  and  the  acute  exanthemata,  yet  this  analogy 
between  the  two  groups  of  diseases  has  been  strongly  advocated,  principally  by 
Bosc,  Gaylord,  Borrel,  and  von  Wasielewski;  the  first  two  observers  basing  their 


PARASITICAL  RELATIONS  OF  CANCER.  389 

advocacy  on  the  ground  of  the  similarity  of  some  of  the  inclusions  in  the  two 
processes,  and  Borrel  and  von  Wasielewski  on  more  general  grounds. 

It  will  perhaps  be  of  interest  to  follow  more  closely  the  relation  which  exists 
between  the  two  processes.  Those  who  discovered  a  resemblance  between  the 
inclusions  found  in  cancer  and  those  observed  in  smallpox  and  vaccinia  were  the 
first  to  call  attention  to  the  analogy  between  the  two  processes.  It  was  Gorini, 
namely,  who  first  detected  points  of  similarity  between  certain  larger  forms  of 
the  vaccine  body  as  they  appeared  in  the  inoculated  corneas  of  rabbits  and  the 
cell  inclusions  of  cancer.  This  similarity  applies  only  to  certain  larger  forms  of 
the  vaccine  body  which  had  been  previously  described  by  L.  Pfeiffer,  Guarnieri, 
and  Clarke,  but  Gorini  was  able  to  trace  a  gradual  transition  between  the  larger 
typical  vaccine  bodies  and  these  larger  inclusions,  which  resemble  the  inclusions 
in  cancer.  In  1900  the  writer  observed  a  similarity  between  certain  of  the  can- 
cer inclusions  and  certain  forms  of  the  vaccine  organism,  and  from  this  observa- 
tion it  was  inferred  by  him  that  if  the  inclusions  in  vaccine  were  parasites,  then 
in  all  probability  the  inclusions  in  cancer  were  of  the  same  nature.  On  the  same 
day  of  the  same  year  Bosc  published  an  article  in  which  he  advanced  exactly 
the  same  idea.  At  the  same  time  he  called  attention  to  the  fact  that  in  the  le- 
sions of  sheep-pox  also  there  were  bodies  which  bore  a  close  resemblance  to  some 
of  the  cancer  inclusions.  Sheep-pox  is  characterized  by  the  development  of  both 
epithelial  and  connective-tissue  nodules  in  the  subcutaneous  tissue.  Bosc  found, 
in  the  exudate  from  fresh  pustules,  characteristic  epithelial  cells  containing 
highly  refractive  bodies  surrounded  by  a  clear  zone  of  protoplasm;  in  other 
words,  inclusions  closely  resembling  those  described  in  the  epithelial  cells  of  can- 
cer. Similar  inclusions  were  found  in  the  cells  forming  the  connective-tissue 
nodules.  A  sheep's  cornea  inoculated  with  the  virus  of  sheep-pox  presented  le- 
sions very  similar  to  those  resulting  from  the  inoculations  of  the  rabbit's  cornea 
with  vaccine,  and  Bosc  believed  that  sheep-pox  represented  an  infection  lying 
midway  between  the  malignant  epithelial  processes  and  the  infectious  exan- 
themata. It  is  unnecessary  to  state  that  the  parasitic  natvue  of  these  inclusions 
cannot  be  proved  by  histological  methods  alone;  and  the  experiments  thus  far 
made  with  cancer  have  failed  to  bring  any  proof  of  its  specific  qualities.  On  the 
other  hand,  the  work  of  Councilman  and  Calkins  and  of  Bosc  and  Howard  has 
again  brought  the  significance  of  the  vaccine  and  variola  inclusions  into  the  fore- 
ground, and  it  must  be  recognized  that  if  these  last  inclusions — which  are  ap- 
parently incapable  of  cultivation  and  which  are  demonstrated  by  methods  simi- 
lar to  those  employed  in  the  case  of  cancer  inclusions,  but  which  present  more 
specific  characteristics  than  do  the  latter — are  ultimately  shown  to  be  parasites, 
then  there  is  a  prospect  that  future  investigation  may  show  that  the  inclusions 
ioimd  in  cancer  are  also  of  the  same  nature. 

Arguments  in  favor  of  the  parasitic  factor  in  cancer  can,  however,  be  adduced 
without  the  aid  of  these  inclusions. 


390  AMERICAN  PRACTICE  OF  SURGERY. 

GENERAL  ARGUilENTS  IN  FAVOR  OF  THE  INFECTIOUS  NATURE 

OF  CANCER. 

Transplantation  Experiments. 
Experimental  methods  in  cancer  research  have  opened  a  new  era.  This  has 
been  made  possible  by  the  discovery  of  the  transplantability  of  tumors  in  animals 
of  the  same  species,  the  first  extensive  demonstration  of  which  we  owe  to  Hanau, 
who  succeeded  in  transplanting  to  the  third  generation  a  carcinoma  of  the  rat. 
Before  Hanau,  however,  as  early  as  1875,  Nowinsky  succeeded  in  transplanting 
a  medullary  carcinoma  taken  from  the  nose  of  a  dog,  successfull}^  in  two  out  of 
forty-two  inoculated  clogs.  Wehr  in  1883  succeeded  in  transplanting  a  medul- 
lary carcinoma  from  the  vaginal  mucosa  of  a  bitch  into  a  number  of  dogs. 
Most  of  these  tumors  retrograded,  but  in  one  animal  the  tumors  grew  to  con- 
siderable size  and  produced  metastases  in  the  adjacent  lymph  nodes.  Follow- 
ing Hanau,  Morau  in  France,  Leo  Loeb  in  America,  Jensen  in  Copenhagen, 
Borrel  in  Paris,  Ehrlich  in  Frankfurt,  Bashford  in  London,  and  the  New  York 
State  Cancer  Laboratory  in  Buffalo  have  all  experimented  with  the  trans- 
plantation of  primary  tumors — mosth^  in  mice,  Loeb's  first  observations 
being  on  a  sarcoma  of  the  rat.  The  extent  to  which  this  work  is  now  being  car- 
ried on  can  be  appreciated  when  it  is  stated  that  one  tumor  alone,  that  of  Jensen, 
is  now  being  worked  upon  in  at  least  seven  laboratories,  and  that  this  tumor  has 
been  transplanted  to  somewhere  near  the  eightieth  generation. 

The  attention  which  has  been  attracted  to  the  occurrence  of  primary  tumors 
in  mice  has  led  to  the  discovery  of  a  large  number.  Thus  Ehrlich  has  succeeded 
in  collecting  tumors  in  154  white  and  10  gray  mice;  Bashford  collected  9;  Loeb 
has  recently  detected  a  spontaneous  tumor  in  a  mouse ;  and  the  New  York  State 
Laboratory  is  in  possession  of  8  primary  tumors.  Borrel  has  secured  in  Paris  30 
examples  of  spontaneous  tumors  in  mice,  and  Haaland  speaks  of  62  cases  known 
to  the  authorities  of  the  Pasteur  Institute.  The  latter  authority  calls  attention 
to  the  fact  that  the  62  spontaneous  tumors  observed  in  Paris  were  all  in  elderly 
females,  and  that  all  of  the  tumors  were  adenocarcinomata,  involving  the  ab- 
dominal aspect,  the  axilla?,  the  groins,  or  the  neighborhood  of  the  anus  or  the 
vulva  of  these  mice.  They  were  all  derived  from  the  breast.  Ehrlich  likewise 
calls  attention  to  the  fact  that,  of  164  spontaneous  tumors  observed  in  his  lab- 
oratory, all  occurred  in  aged  females  and  were  all  positively  derived  from  the 
mamma.  Eight  out  of  nine  of  Bashford's  mice  were  elderly  females,  and  the 
tumors  were  likewise  all  derived  from  the  breast;  in  the  one  exceptional  case — 
that  of  a  male — the  tumor  was  situated  near  the  root  of  the  tail  and  presented 
the  same  characteristics  as  the  other  tumors.  Of  the  eight  tumors  observed  in 
Buffalo,  seven  were  in  females,  the  sex  of  the  eighth  having  been  unfortunately 
overlooked.  They  all  presented  characteristics  similar  to  those  observed  in  the 
recognized  adenocarcinomata  derived  from  the  breast  in  the  mouse. 


PARASITICAL  RELATIONS  OF  CANCER.  391 

The  fact  that  all  of  these  tumors  were  derived  from  the  breast,  and  the  fur- 
ther fact  that  the  mouse  appears  to  be  much  more  frequently  affected  by  carci- 
noma than  are  other  small  animals,  can  only  be  explained,  as  Ehrlich  has  pointed 
out,  by  the  facts  that  all  of  these  mice  were  obtained  from  dealers  who  were  en- 
gaged in  raising  white  mice  for  the  market  and  that  all  the  females  are 
employed  for  breeding  purposes.  The  fact  that  almost  all  of  the  tumors  have 
appeared  in  elderly  females  certainly  points  to  the  probability  that  the  tremen- 
dous demands  made  upon  the  mammary  tissue  of  these  animals  explain  the 
almost  exclusive  appearance  of  this  form  of  the  tumor.  In  connection  with  these 
facts,  the  observation  of  Borrel  that  healthy  mice,  when  kept  for  a  sufficient 
period  of  time  in  the  same  cage  with  infected  mice,  may  develop  spontaneous 
tumors,  is  of  the  greatest  importance.  It  has  likewise  been  observed  that 
wherever  one  spontaneous  tumor  developed  in  any  particular  locality  where  the 
mice  are  being  bred,  either  simultaneously  or  later,  mice  with  similar  tumors 
have  been  found. 

COMMUNICABILITY    OF    CaNCERS    IN    MiCE. 

The  most  striking  example  of  the  endemic  occurrence  of  cancer  is  described 
by  Borrel,  who,  in  the  course  of  two  years,  observed  in  one  breeding  place  twenty 
cases  of  carcinoma  of  the  breast.  All  of  these  mice  had,  at  one  time  or  another, 
been  in  the  same  cage.  He  observed  further,  in  a  second  case,  in  the  course  of 
■one  year,  five  or  six  cancer  mice,  all  of  which  developed  in  one  cage.  A  similar 
endemic  occurrence  of  cancer  in  the  rat  was  observed  by  Hanau,  who  first  suc- 
cessfully transplanted  cancer  in  this  animal.  He  observed  in  the  course  of  six 
years  three  cases  of  squamous  epithelioma  of  the  vulva.  There  were  in  all  about 
one  hundred  rats,  all  the  offspring  of  two  pairs.  Perhaps  the  most  striking  evi- 
dence of  cage  infection  is  found  in  an  observation  recently  made  in  the  State 
Cancer  Laboratory,  combined  with  a  previous  observation  made  by  Leo  Loeb.  Loeb 
states  that  in  January,  1900,  there  developed  in  a  group  of  cages  containing  rats 
in  the  Chicago  Polyclinic  Laboratory  a  spontaneous  sarcoma  of  the  thyroid.  In 
November  of  1901  a  second  case  of  sarcoma  of  the  thyroid  developed  in  the  same 
group  of  cages,  and  in  the  autumn  of  1903  a  third  case.  The  rats  had  been  moved 
about  from  cage  to  cage  and  were  all  the  offspring  of  a  certain  limited  nimiber  of 
rats.  The  tumors  presented  identical  histological  characteristics.  The  first  and 
second  rat  tumors  were  vised  for  transplantation,  in  both  cases  successfully.  On 
transplantation  the  tumor  presented  the  characteristics  of  spindle-celled  sar- 
coma, which  in  many  animals  produces  characteristic  regional  and  organal 
metastases.  Sections  of  this  tumor  have  been  repeatedly  shown  at  scientific 
meetings,  and  there  is  absolutely  no  question  as  to  its  being  a  genuine  spindle- 
celled  sarcoma.  The  spring  and  summer  of  1902  were  spent  by  Dr.  Loeb  at  the 
State  Cancer  Laboratory  in  Buffalo.  He  was  provided,  for  the  accommodation 
of  his  animals,  with  two  large  and  a  number  of  small  cages.  He  brought  with 
him  a  number  of  rats  which  had  been  inoculated  from  his  second  sarcoma  of  the 


392  AMERICAN  PRACTICE  OF  SURGERY. 

thyroid  obtained  in  Chicago.  During  the  period  of  his  stay  in  Buffalo  ne  carried 
out  a  number  of  successful  transplantations.  On  leaving  the  laboratory  in  Sep- 
tember he  took  with  him  a  number  of  rats  with  tumors,  but  these  became  in- 
fected, and  later  the  tumor  was  so  infected  as  to  be  no  longer  transplantable. 
After  Dr.  Loeb's  departure  all  rats  were  removed  from  the  laboratory.  The 
smaller  cages  were  sterilized  in  the  hot-air  sterilizer,  but  the  two  larger  cages 
which  he  had  employed,  being  too  large  for  such  steriUzation,  were  simply 
cleaned  and  put  away.  For  a  period  of  several  months  after  Dr.  Loeb's  depart- 
ure there  were  no  rats  of  any  kind  in  the  laboratory.  In  the  summer  of  1903 
some  rats  were  purchased  in  Buffalo  for  other  purposes  than  tumor  transplanta- 
tion, and  a  number  of  them  were  placed  in  the  two  large  cages  mentioned.  In 
the  spring  of  1904  there  was  found  in  one  of  these  cages  a  rat  with  a  tumor  the 
size  of  a  horse-chestnut  in  the  subcutaneous  tissue  of  the  right  abdominal  aspect. 
This  tumor  was  removed  by  operation,  and  proved  to  be  a  fibro-sarcoma.  It 
was  transplanted  to  other  rats,  but  without  success.  The  occurrence  of  the 
development  of  this  sarcoma  in  the  rat  was  noted  and  the  cage  was- marked. 
There  were  then  introduced  into  the  cage  a  number  of  adult  rats,  but,  owing  to 
an  epidemic  of  itch  among  them,  it  was  found  necessary  to  remove  the  cages 
containing  them  to  the  basement  to  prevent  the  possible  spread  of  this  infection 
to  the  hundreds  of  mice  which  occupied  the  regular  animal  space  in  the  labora- 
tory. During  the  summer  of  1905  there  were  found  in  this  cage  two  adult  rats, 
both  males,  one  with  a  large  fibro-sarcoma  in  the  right  abdominal  aspect  and  the 
other  with  a  large  sarcoma  of  the  thyroid.  The  latter  rat  died  early  in  October. 
Sections  of  the  tumor  showed  it  to  be  identical  in  appearance  with  the  three 
primary  sarcomas  of  the  thyroid  described  by  Loeb,  which  developed  in  the 
cages  in  the  Chicago  Polyclinic  Laboratory.  In  the  middle  of  October  an  opera- 
tion was  performed  upon  the  other  rat.  Sections  showed  that  the  tumor  was  a 
fibro-sarcoma  of  identical  appearance  with  the  one  which  had  appeared  in  the 
cage  a  year  before.  A  number  of  rats  had  died  during  the  course  of  the  summer 
with  tuberculosis,  so  that  at  the  time  of  the  development  of  the  tumors  there 
were  but  four  adult  rats  in  the  cage,  the  two  with  the  tumors  and  two  without. 
No  other  tumors  have  developed  in  rats  in  any  of  the  other  cages  in  the  labora- 
tory, although  the  small  cages  employed  by  Dr.  Loeb  and  subsequently  sterilized 
have  now  had  rats  in  them  for  a  period  of  two  years.  Aside  from  the  three  cases 
of  primary  sarcoma  of  the  thyroid  developed  in  Chicago  and  described  by  Dr. 
Loeb,  during  the  period  of  three  years  since  his  departure  from  the  laboratory 
with  his  inoculated  rats  no  other  author  has  described  sarcoma  of  the  thyroid  in 
the  rat,  and  none  has  been  known  to  develop  in  any  of  the  establishments  in 
which  these  animals  are  bred.  The  demand  for  animals  with  tumors  has  become 
so  great  that  all  breeders  of  white  mice  and  white  rats  are  now  on  the  lookout 
for  tumors,  so  that  the  possibility  of  their  having  been  overlooked  is  reasonably 
remote. 


PARASITICAL  RELATIONS  OF  CANCER.  393 

Haaland  calls  attention  to  a  case  in  wliich  a  woman  in  Paris  purcliased  two 
white  mice  for  breeding  purposes.  In  the  course  of  two  years  she  sold  about  two 
hundred  young  offspring,  reserving  the  mature  mice  for  breeding  purposes. 
Among  these  she  observed  twenty  spontaneous  tumors.  The  last  three  of  these 
mice,  with  the  cage  in  which  they  had  developed  their  tumors,  were  brought  to 
the  Pasteur  Institute.  The  mice  were  removed  from  the  cage  and  were  placed 
in  a  new  cage,  and  into  the  cage  in  which  they  had  developed  their  tumors  were 
placed  new  mice.  None  of  the  mice  which  had  previously  been  in  the  cage  in 
which  the  tumor  developed,  or  the  new  mice  which  had  been  placed  in  it,  devel- 
oped tumors  under  subsequent  observation.  The  three  mice,  however,  which 
had  already  developed  sporadic  tumors  were  placed  in  a  new  cage,  and  in  this 
cage  were  placed  with  them  a  number  of  mice  derived  from  healthy  stock,  their 
ancestors  so  far  as  known  never  having  had  sporadic  tumors.  Of  the  healthy 
mice  thus  placed  in  contact  with  the  mice  already  infected,  four  developed  spon- 
taneous tumors.  From  this  it  would  appear  that  to  a  certain  extent  these  mouse 
tumors  are  contagious.  If  this  be  admitted,  what  is  the  significance  of  the  almost 
exclusive  development  of  primary  carcinoma  of  the  mamma  in  elderly  females 
among  these  mice?  Ehrlich  points  out  that  two  explanations  are  possible.  First 
of  all,  by  reason  of  the  great  fertility  of  the  animals  the  older  females  are  almost 
constantly  carrying  and  nursing  young.  It  is  therefore  reasonable  to  assume  that 
the  tremendous  demands  made  upon  the  breast  predispose  to  an  unlimited  pro- 
liferation of  the  epithelium  of  that  gland.  On  the  other  hand,  it  is  probable  that, 
through  the  indiscriminate  nursing  of  the  young,  first  by  one  mother  and  then  by 
another,  an  infection  of  the  breast  in  one  mouse  might  easily  be  transferred  to 
that  of  another  mouse.  It  has  been  shown  that  in  the  early  stages  of  carcinoma 
the  breast  still  possesses  the  power  of  lactation,  and  it  is  therefore  perfectly  pos- 
sible that,  through  eversion  of  the  nipple,  the  virus  may  be  transferred  from  that 
structure:  in  one  animal  to  the  corresponding  structure  of  another.  Both  in 
Paris  and  in  Ehrlich's  laboratory  careful  experimentation  is  being  carried  on  for 
the  purpose  of  ascertaining  whether  or  not  this  occurrence  can  be  experimentally 
proven.  In  the  light  of  Borrel's  observation — viz.,  that  healthy  mice  which  are 
brought  in  contact  with  infected  mice  can  acquire  these  tumors — it  would  seem 
that  the  exclusive  appearance  of  tumors  of  the  breast  among  animals  used  solely 
for  breeding  purposes  presents  very  suggestive  evidence  in  favor  of  an  infectious 
factor. 

Transference  of  the  Infectious  Factor  in  Cancer  Cells  to  Normal 

Epithelium. 

The  evidence  thus  far  adduced  applies  only  to  primary  tumors.  If  there  is  a 
contagious  factor  which  can  be  transferred  from  one  animal  to  another,  bringing 
about  the  transformation  of  normal  epithelial  cells  into  cancer  cells,  then  it  is  not 
improbable  that,  in  the  very  beginning  of  cancer,  this  contagious  factor  may  be 


394  AilERICAX   PRACTICE  OF   SURGERY. 

transferred  for  a  limited  period  from  one  cell  to  the  next.  In  fact,  pathologists 
generally  recognize  that,  in  small,  beginning  carcinomata,  such  a  transformation 
can  be  observed.  We  have  from  Orth,  in  his  most  recent  utterance  on  this  sub- 
ject, the  following:  "I  am,  I  confess,  of  the  opinion  that  there  are  cancers  in 
which  the  transformation  of  preformed  epithelial  cells  into  cancer  cells  takes 
place  continuously  in  the  tissue  bordering  upon  the  margin  of  primary  tumors; 
also  that  there  are  multicentric  cancers,  not  only  in  the  sense  that  the  cancer 
change  takes  place  at  the  same  time  in  different  neighboring  spots,  but  also  in 
such  a  manner  that  one  spot  becomes  cancerous  later  than  another."  If  a  pri- 
mary cancer  starts  from  a  given  centre  and  the  cancerous  transfoimation  spreads 
from  cell  to  cell,  it  must  be  that  that  force  or  factor  which  endows  normal  epi- 
thelium with  the  power  of  limitless  proliferation  is  transferred,  at  least  for  a  cer- 
tain period  of  time,  from  the  iuA^oh^ed  cells  to  the  adjoining  normal  ones.  Al- 
though this  appears  to  be  the  case  in  the  period  of  the  inception  of  a  cancer, 
experimentation  has  shown  that  the  cancer  cell,  once  endowed  with  this  power 
of  proliferation,  retains  it  most  persistently,  and  a  transference  of  this  power  to 
other  cells  never  occm-s,  unless  one  or  two  suggestive  observations,  which  will  be 
referred  to  later,  are  evidences  of  such  transference. 

Success  in  transplanting  these  sporadic  tumors  in  the  mice  has  been  variable, 
but  the  general  experience  tends  toward  more  successes  as  the  work  progresses. 
In  six  of  the  mice  in  which  cancer  was  transplanted  by  Bashford,  there  were  only 
two  in  which  the  disease  persisted  beyond  the  second  generation.  Borrel  is  in 
possession  of  an  epithelioma  and  an  adenocarcinoma  which  are  transplantable, 
and  Ehrlich  has  at  present  ten  different  sporadic  tumors  in  process  of  transplan- 
tation, some  as  advanced  as  the  sixtieth  generation.  Bashford  has  had  over 
three  thousand  transplanted  tumors  imder  observation.  Ehrlich's,  Borrel's,  and 
Jensen's  observations  must  likewise  run  into  high  figures,  and  the  New  York 
State  Laboratory  has  already  had  about  six  hundred.  It  will  thus  be  seen  that 
the  last  two  years  have  been  very  fruitful  in  experience  in  the  investigation  of 
cancer,  and  it  may  be  said  that,  although  the  work  has  just  begun,  manj^  ideas 
which  we  have  held  regarding  this  process  have  been  shown  to  be  erroneous,  and 
many  characteristics  have  developed  which  were  entirely  unexpected. 

Characteristics  of  Traxsplantable  Mouse  Tumors. 

It  must  be  pointed  out  that  the  mere  transplantability  of  cancer  throws  no 
light  upon  the  mechanism  bj'  which  spontaneous  tumors  develop.  These  trans- 
plantations are  modifications  of  the  process  of  metastasis.  The  success  with 
which  they  haA'^e  been  accompanied  has  shown  great  variability,  but  on  the  whole 
the  experiences  of  all  laboratories  have  been  that  tumors  which  have  been  often 
transplanted  acquire  an  increased  virulence,  so  that,  although  the  success  at- 
tending the  first  attempts  at  transplantation  has  in  manj'  cases  been  as  low  as 


PARASITICAL  RELATIONS  OF  CANCER.  395 

one  or  two  per  cent,  in  later  cases  the  virulence  has  risen  to  such  an  extent  that 
the  average  has  been  as  high  as  from  eighty  to  one  hundred  per  cent.  A  most 
interesting  example  of  the  tremendous  virulence  of  these  transplanted  tumors  is 
found  in  one  which  is  imder  observation  by  Ehrlich.  This,  known  as  No.  7  in 
his  series,  presents  a  virulence  which  is  most  astonishing.  The  transplantations 
with  this  tumor  material  have  for  a  considerable  period  of  time  given  from  eighty 
to  one  hundred  per  cent  of  successes.  The  transplanted  tumor  grows  with  such 
rapidity  that  in  eight  days  after  inoculation  it  has  been  found  to  weigh  2  gm. ; 
at  the  end  of  two  weeks,  over  3  gm. ;  and  at  the  end  of  three  weeks,  usually  5 
gm.  Tumors  as  large  as  the  mouse  itself  not  infrequently  develop  within  two 
months  from  the  time  of  inoculation.  All  laboratories  which  have  been  working 
on  transplantation  have  had  similar  experiences.  Some  tumors  are  fomid  to 
grow  very  slowly,  as  did  that  of  Morau,  which  required  months  for  its  full  devel- 
opment, whereas  others  present  the  characteristics  of  the  tumor  described  above. 
In  all  tumors,  however,  repeated  transplantation,  instead  of  weakening  the  en- 
ergy of  the  tumor,  seems  to  increase  its  virulence,  and  it  is  now  recognized  that 
the  most  distinguishing  feature  of  cancer  is  the  unlimited  power  of  proliferation 
which  the  cancer  cells  possess,  this  power  having  already  carried  some  tumors 
beyond  the  sixtieth  generation  of  transplantation  through  healthy  mice. 

All  this  experimentation  has  failed  to  show  us  how  the  cancer  cells  acquire 
this  phenomenal  power  of  proliferation.  That  the  characteristic  factor  of  can- 
cer is  found  only  in  the  epithelium  is  shown  by  the  fact  that  the  stroma  in  the 
transplanted  tumors  is  furnished  by  the  host.  That  this  factor,  in  the  course  of 
transplantation  of  mouse  tumors,  is  occasionally  transferred  to  the  connective- 
tissue  elements  of  the  stroma,  endowing  them  with  sarcomatous  characteristics 
by  which  the  tumor  is  transformed  into  a  mixed  tumor,  is  shown  by  the  fasci- 
nating publications  of  Ehrlich  andApolant  {Berl.  klin.Wochenschr.,  1905,  No.  28, 
and  1906,  No.  2).  These  observers  have  now  encountered  this  phenomenon  in 
three  tumors.  In  the  first  case  observed,  the  tumor  presented  the  usual  char- 
acteristics of  the  adeno-carcinoma  of  the  mouse  and  had  been  transplanted 
without  any  change  to  the  sixth  generation.  The  tumor  consisted  of  nests  of 
varymg  sizes  of  alveolar  arrangement,  with  a  not  very  well  developed  connective- 
tissue  stroma.  Between  the  sixth  and  ninth  generations  the  tumor  underwent 
a  change  in  which  the  carcinoma  suddenly  presented  the  characteristics  of  a 
mixed  tumor,  the  thin  connective-tissue  stroma  presenting  everj^  evidence  of 
active  proliferation;  wide  avenues  of  closely  packed,  deeply  staining  spindle 
•cells,  with  abundant  karyokinetic  figures,  appearing  between  the  nests  of  epi- 
thelium. These  characteristics  persisted  from  the  ninth  to  the  thirteenth  gen- 
eration, the  epithelial  characteristics  graduallj^  diminishing  and  the  nests  becom- 
ing smaller  and  more  widely  separated;  and  in  the  fourteenth  generation  the 
epithelium  had  entirely  disappeared  from  the  tumor,  leaving  a  spindle-celled 
sarcoma,  which  is  still  being  transplanted  and  has  reached  the  fortieth  genera- 


396  AMEPJCAX  PRACTICE  OF  SIT^GERY. 

tion.    The  accompanymg  table   from  Ehrlich  will  serve  more  graphically  to 
emphasize  this  remarkable  observation : 

Familv  16  Carcinoma 

I 

1  Generation  Carcinoma 

2  Generation  Carcmoma 

I 
6  Carcinoma 

I 
9 


Mixed  tmiior  10b  10a  Mixed  tumor 

I 
11 

. I 

I  !  I 

12a  12b  12c  mixed 


13a  Sarcoma  13b  ilixed  13c  Mixed 

I 
1-4  Sarcoma 

I 
15  Sarcoma 

The  generations  marked  a,  b,  c  descended  from  various  mice  of  the  preceding 
series. 

Recently  Apolant  and  Ehrlich  have  reported  two  further  similar  obser\-a- 
tions.  In  one  of  these  the  sarcomatous  transformation  developed  in  an  adeno- 
carcinoma which  was  produced  by  mixing  together  various  adeno-carcinomata 
which  were  respective^  in  the  twentj'- first,  the  thirtj^-third,  the  twenty- third, 
and  the  nineteenth  generations  of  transplantations.  One  of  the  strains  derived 
b}'^  this  mixture,  between  the  twelfth  and  fovuteenth  generations,  showed  a 
marked  increase  in  the  proliferation  of  the  coimective-tissue  stroma,  which 
awakened  at  once  the  suspicion  that  the  development  of  sarcoma  was  taking 
place.  In  the  sixteenth  generation  this  was  so  far  developed  that  the  tumor 
presented  the  characteristics  of  a  mixed  tumor.  In  contrast  to  the  first  case 
reported,  the  differentiation  between  the  nests  of  epithelial  cells  and  the  prolif- 
erating stroma  was  not  nearly  so  marked  as  in  the  preceding  case.  The 
sarcoma  cells  likewise  were  more  polymorphous  in  appearance,  typical  spindle 
cells  forming  only  a  part  of  the  tumor.  They  lay  in  irregular  masses  that  filled 
the  spaces  not  occupied  by  the  net-like  structure  of  the  epithelial  portion  of 
the  timior.  The  proliferative  cliaracteristics  of  the  sarcomatous  portion  of  the 
tumor  were  not  nearly  so  marked  as  in  the  first  case.  The  tumor  at  present 
is  in  its  tenth  generation  of  txansplantation,  and  the  proliferation  of  the  connec- 
tive-tissue and  epithelial  elements  appears  to  be  about  on  the  same  footing 
as  it  was  before,  the  tumor  ha\-ing  during  the  last  six  months  shown  but 


PARASITICAL  RELATIONS  OF  CANCER.  397 

slight  changes  in  the  relative  proportion  of  epithelium  and  connective  tissue. 
The  rapidity  of  growth  of  this  tumor  shows  no  diminution,  the  authors  having 
observed  tumors  of  enormous  size,  in  many  cases  equal  to  that  of  the  mouse  itself. 

The  third  observation  is  the  most  striking  of  all.  It  occurred  in  the  course  of 
transplantation  of  Ehrlich's  tumor  No.  7,  which  is  the  most  virulent  of  all  mouse 
tumors  yet  imder  observation.  This  tumor  had  shown,  from  the  fortieth  to  the 
sixty-eighth  generation,  a  marked  increase  in  the  connective  tissue  without  the 
stroma  presenting  the  characteristics  of  a  sarcoma,  when  suddenly  in  the 
sixty-eighth  generation  it  took  on  a  marked  sarcomatous  appearance,  associated 
with  such  colossal  proliferation  that  in  the  next  generation  many  of  the  tumors 
were  sarcomas  without  any  evidence  of  epithelioma.  Here  and  there  some  of 
the  transplanted  tumors  contained  a  few  nests  of  epithelium.  These  remnants 
of  carcinomatous  epithelium  have  been  detected  as  late  as  the  seventy-first 
generation.  The  sarcoma  cells  in  this  tumor  were  likewise  more  polymorphous 
in  character,  those  of  a  spindle  shape  being  in  a  minority.  This  timior  has 
now  been  transplanted  three  generations  further  without  any  loss  of  the 
colossal  proliferative  qualities  with  which  it  has  been  endowed  from  the  first. 
The  explanation  of  this  phenomenon  given  by  Ehrlich  is  that  some  form  of 
stimulus  present  in  the  carcinoma  cells  is  in  certain  phases  of  its  development 
transferred  from  the  epithelium  to  the  connective-tissue  stroma  of  the  tumor  and 
transforms  the  connective-tissue  cells  of  this  structure  into  typical  sarcoma 
cells  capable  of  probably  indefinite  transplantation. 

It  is  impossible  to  draw  conclusions  from  a  single  observation,  but  the  phe- 
nomenon described  above  may  possibly  be  explained  by  the  assumption  that  the 
chief  characteristic  of  a  cancer — viz.,  its  power  to  proliferate  to  an  unlimited 
extent — has,  in  this  particular  instance,  been  transferred  from  the  epithelium  to 
the  connective  tissue.  To  assume,  on  the  other  hand,  a  transformation  of  epi- 
thelial cells  into  connective-tissue  cells,  would  be  contrary  to  all  our  histological 
loiowledge.  It  can,  of  course,  be  said  that  the  phenomenon  under  consideration 
represents  merely  the  sporadic  development  of  a  sarcoma  on  the  basis  of  a  car- 
cinoma. That  the  ^--factor  in  cancer  may  possibly  be  transferred  to  other  cells 
is  shown  by  the  frecjuent  observations  referred  to  by  Haaland,  and  observed  in 
Buffalo,  of  the  development  of  primary  adenomata  in  the  lungs  of  mice  which 
have  been  the  subject  of  transplantation  of  these  mammary  tumors.  Haaland 
refers  to  the  fact  that  this  primary  development  of  adenomata  in  the  lungs  of 
mice  is  a  not  uncommon  occurrence,  and  our  own  observations  corroborate  this 
statement. 

Natural  Immunity  to  Implantation  in  Mice. 

It  has  been  foimd  in  all  laboratories  that  a  certain  proportion  of  mice  cannot 
be  inoculated  with  the  tumor.  Thus  far,  a  natural  immunity  against  these  in- 
oculation experiments  appears  to  bear  no  definite  relation  to  heredity,  but  in  all 


398  AMERICAN  PRACTICE  OF  SURGERY. 

laboratories  mice  have  been  found  which  appear  to  be  permanently  immune, 
and  these  mice  have  frequently  been  the  offspring  of  parents  both  of  which  were 
afterward  successfully  inoculated  and  died  of  the  tumors. 

Spontaneous  Retrogression  in  Cancer  of  the  Mouse. 

Although  the  disease,  once  established  by  implantation,  is  in  a  very  large  per 
cent  of  the  cases  fatal,  in  all  laboratories  occasionally  spontaneous  cures  have 
occurred.  These  have  been  observed  in  Ehrlich's  laboratory  and  also  by  Bash- 
ford;  and  apparently,  up  to  the  present  time,  the  greatest  number  have  occurred 
in  the  Jensen  mice  under  observation  in  the  State  Laboratory  in  Buffalo.  Im- 
mediately following  the  transplantation  of  these  tumors — which  is  done  by  tak- 
ing uncontaminated  tumor,  mixing  it  in  a  mortar  with  three  or  four  parts  of 
normal  salt  solution,  and  injecting  it  beneath  the  skin  of  the  back  through  a 
coarse  needle  with  a  syringe  or  introducing  particles  through  a  small  trocar — 
there  is  frequently  a  slight  reaction,  which  subsides  on  the  second  or  third  day. 
It  is  obvious  that  in  many  of  these  experiments  transient  infection  occurs,  as 
shown  by  the  formation  of  an  abscess.  This  usually  interrupts  the  experiments 
but  occasionally  the  swelling  subsides  and  ultimately  a  tumor  develops. 

In  the  period  from  February  to  June,  1905,  not  less  than  twenty  per  cent  of  the 
tumors  resulting  from  successful  inoculation  underwent  spontaneous  retrogres- 
sion. This  is  a  higher  percentage  of  spontaneous  recoveries  than  has  yet  been 
reported  from  any  other  laboratory.  The  distribution  of  the  period  in  which  the 
processes  of  retrogression  were  apparent  shows  that  more  spontaneous  retro- 
gressions occurred  early  in  the  process  than  late.  There  are,  however,  a  certain 
number  of  retrogressions  which  occurred  in  what  would  normally  be  the  last 
stages  of  the  disease.  One  of  the  most  striking  examples  occurred  in  a  rapidly 
growing  tumor,  which  reached  a  weight  of  over  3  gm.  in  forty-three  days  after 
the  inoculation,  then  began  to  retrograde  and  ultimately  disappeared. 

That  a  spontaneous  cure  of  a  genuine  carcinoma  in  the  mouse  should  occur 
and  should  be  well  authenticated  would  at  first  seem  surprising,  but  a  careful 
review  of  the  literature  has  shown  that  undoubted  cases  of  spontaneous  cui'e 
have  also  been  observed  in  human  beings.  It  is  natural  that  a  greater  percentage 
of  these  cures  should  occur  under  experimental  conditions  than  under  the  con- 
ditions in  which  we  encounter  cancer  at  the  bedside.  Mice  used  for  experimen- 
tation are  taken  at  random,  and  it  is  obvious  that  some  of  them  have  a  greater 
resisting  power  than  others,  as  shown  by  the  fact  that  a  certain  percentage  of 
them  possess  a  natural  immunity  which  protects  them  from  being  successfully 
inoculated.  The  cases  which  we  meet  clinically  are  those  of  individuals  who  ap- 
parently have  no  sufficient  immunity,  and  we  see  therefore  only  the  unfavorable 
cases.  It  is  not  improbable,  however,  that  even  in  human  beings  patients  be- 
come infected  with  cancer,  but  make  early  spontaneous  recoveries,  perhaps  with- 
out attracting  even  their  own  attention. 


PARASITICAL  RELATIONS  OF  CANCER. 


399 


Evidence  of  an  Acquired  Immunity  against  Cancer  in  Mice. 

Researches  in  the  State  Laboratory  as  to  the  nature  of  the  phenomena  asso- 
ciated with  spontaneous  cure  point  very  strongly  toward  the  presence,  in  mice 
which  have  recovered  spontaneously,  of  a  form  of  acquired  immunity.  This  is 
shown  by  the  failure  successfully  to  reinoculate  any  mouse  which  has  spontane- 
ously recovered.  The  immune  factor  is  apparently  present  in  the  blood,  and  in 
some  mice  has  been  sufRciently  active,  when  injected  into  other  mice  with  grow- 
ing tumors,  to  influence  the  growth  of  the  tumor.  In  this  way  small  tumors  have 
been  made  to  retrograde  and  large  tumors  have  been  inhibited  in  their  growth. 
Further  proof  of  the  presence  of  an  immune  factor  in  the  blood  of  mice  is  found 
in  the  recent  observations  of  Clowes,  which  show  that  when  cancer  material  is 
treated  with  a  sufficient  proportion  of  the  blood  of  spontaneously  recovered 
mice  the  number  of  successful  inoculations  is  markedly  reduced. 


Histological  Char.\cteristics  of  Retrograding  Mouse  Tumors. 

Examinations  of  the  histological  appearance  of  tumors  undergoing  spontane- 
ous retrogression,  and  of  those  retrograding  under  the  influence  of  injections 
with  immune  serum,  show  identically  the  same  picture.    If  the  action  of  this 


Fig.  119. — Microphotograpli. 


X  260.      Epithelium  at  Margin  of  Tumor  Undergoing  Retrogression 
from  x-ray  Treatment, 


serum  were  cytolytic  in  its  nature,  we  should  expect  to  find  evidences  of  destruc- 
tion or  direct  injury  to  the  cells,  but  this  is  not  the  case.  About  the  margins  of 
retrograding  tumors  one  finds  that  the  cells  have  undergone  simple  atrophy,  and 
that  where  groups  of  cells  remain  they  frequently  coalesce  into  pseudo-giant 


400  AMERICAN   PRACTICE   OF   SURGERY. 

cells.  These  are  surrouiided  by  connective  tissue,  and  ultimatelj',  through  the 
process  of  atrophy,  disappear.  In  tumors  undergoing  retrogression  hemorrhage 
is  a  frequent  occurrence.  An  examination  of  the  cancer  cells  immediatel}'^  adja- 
cent to  the  hemorrhages  in  the  tumor  shows  that  this  process  of  simple  atrophy 
is  most  marked  where  the  cells  have  come  in  contact  with  the  extravasated 
blood.  Practicalh^,  one  can  see  here  the  direct  action  of  the  blood  upon  the  cells. 
There  is  no  necrosis  of  the  protoplasm,  and  karyokinetic  figures  can  be  found  in 
the  epithelial  cells  until  the  very  last.  The  picture  presented  shows  that  the 
epithelial  cells  are  subjected  to  a  process  which  is  identical  with  that  which  over- 
takes transplanted  or  misplaced  normal  epithelium.    Leo  Loeb  and  others  have 


Fig.  120. — Section  of  Wart  Tlurteen  Days  after  First  Treatment,  Nine  Days  After  Last  Treatment 
witli  2:-ray,  Showing  Complete  Hornifieation  of  Epithelium  of  Wart  and  New  Skin  Formed  from 
Deeper  Layers.      (Perthes.) 

sho\\'n  that  if  fcetal  epithelium  is  asepticalh^  transplanted  into  the  subcutaneous 
tissues  m  adult  animals,  it  is  able  to  maintain  itself  for  a  period  of  time  during 
which  its  d3'namic  force  suffices  for  proliferation  to  the  sixth  or  seventh  genera- 
tion, after  which  the  force  is  expended,  the  cells  undergoing  atrophj'  and  becom- 
ing surromided  b}'  connective  tissue,  which  grows  between  them.  The  picture 
presented  here  is  exactly  like  that  fomid  in  these  retrograding  tumors. 

From  this  observation  it  must  seem  obvious  thatinspontaneousl3M'etrograding 
tumors  the  immune  factor,  instead  of  working  directly  upon  the  cells,  reduces 
them  to  the  status  of  normal  epithelium,  and  thej'  are  then  removed  by  a  process 
of  atrophy  and  repair  which  is  identical  with  that  which  overtakes  misplaced 
normal  epithelial  elements.     Becher,  Petersen,  and  Schwartz  have  shown  that 


PARASITICAL  RELATIONS  OF  CANCER. 


401 


similar  reparative  processes  are  frequent!)'  at  ^vorI<;  in  manj^  human  carcinomata. 
That  the  connective-tissue  activity  is  secondary  is  shown  by  interference  with 
the  immune  mechanism,  which  interference  can  be  brought  about  by  bleeding. 
In  the  New  York  State  Laboratory  it  has  been  found  that  in  the  case  of  tumors 
which  were  undergoing  retrogression  as  the  result  of  injections  of  immmie  sera, 
severely  bleeding  the  mouse  would  interrupt  the  process  and  the  tumor  would 
thereupon  begin  to  grow  as  rapidly  as  ever.  This  observation,  in  connection 
with  the  facts  which  tend  to  show  that  the  immune  factor  is  in  the  blood,  strongly 


Fig.  121, — Section  of  Untreated  Wart  for  Comparison.      {Perthes.) 

indicates  that  the  proliferation  of  the  connective  tissue  is  but  a  secondary  process, 
which  only  becomes  active  when  the  cancer  cells  are  reduced  to  the  status  of 
normal  epithelium. 


Identity  of  Histological  Characteristics  of  Spontaneously  Retrograd- 
ing Tumors  and  Tumors  Retrograding  through  Treatment  with  Im- 
mune Sera,  the  x-Ray,  or  Radium. 

The  changes  which  are  brought  about  in  carcinoma,  either  in  man  or  in  ani- 
mals, by  exposing  them  to  the  activities  of  the  x-ray  or  of  radium,  have  been 
shown  by  Exner,  Perthes,  and  others  in  man,  and  by  Apolant  and  Embden  and 
Bashford  in  mice,  to  present  exactly  the  same  histological  picture  as  that  which 


402  AMERICAN  PRACTICE  OF  SURGERY. 

is  presented  bj^  timiors  midergoing  spontaneous  retrogression.  This  fact  has 
been  under  observation  for  over  a  year  in  Buffalo.  A  section  of  a  tumor  retro- 
grading under  the  activity  of  the  x-ray  or  of  radium  is  in  no  way  distinguishable 
from  one  taken  from  a  tumor  undergoing  spontaneous  retrogression  or  retro- 
gression induced  by  serum  treatment.  Examination  of  the  blood  of  mice  which 
have  recovered  from  timiors  through  the  activity  of  the  x-iay  shows  that  this 
fluid  does  not  contain  any  acquired  immune  factor.  If,  however,  in  the  course 
of  treatment  a  mouse  is  heavily  bled,  the  tumor  will  frequently  begin  to  grow — 
a  phenomenon  which  leads  to  the  conclusion  that  the  .x-ray  does  not  act  direct!}^ 
upon  the  tumor,  but  through  svich  immune  factors  as  the  mouse  still  possesses. 

•  !•  •  *••  '-  •  ^"*f^,-®''    ..V-  .•  5  •  ":  ••  ■^- •*  S     '  y^  ^^' 

Fig.  122. — Human  Tumor  Undergoing  Retrogression  from  Treatment  with-r-raj'.      (After  Perthes.) 

For  this  reason  it  would  appear  that  the  .r-ra}^  and  radium  reduce  the  virulence 
of  the  tumor  or  so  injure  the  z-factor  that  the  natural  immmiity  brings  about  the 
retrogression  of  the  timior.  In  this  way  it  is  possible  to  explain  those  tiuiiors 
which  are  not  affected  by  the  .r-raj^,  and  also  the  fact — which  has  been  fre- 
quently observed — that  tumors  which  are  being  favorabh*  affected  suddenly  be- 
gin to  grow  in  spite  of  continued  treatment. 

Significance  of  Perthes'  Experiments  with  the  x-Ray  on  Warts. 

That  the  .T-ray,  either  directly  or,  as  would  appear,  indirectly,  robs  the  epi- 
thelial cell  of  the  factor  which  causes  its  vmlimited  proliferation,  and  leaves  the 
normal  epithelial  cells  unaffected,  is  showoi  bj'  the  interesting  experiments  on 
warts  by  Perthes.  Perthes  has  clearly  demonstrated  that  the  dose  of  x-ray  re- 
quired in  the  treatment  of  cancer,  or  for  the  removal  of  warts,  does  not  injure 
directly  either  the  normal  epithelivuii  or  the  epithelial  cells  of  the  tumor.  If  the 
tissues  surrounding  the  tumor  are  o^^erdosed  a  so-called  x-ray  burn  may  be 
induced,  but  this  is  an  injury  entirely  independent  of  the  ideal  therapeutic  ac- 
tivity of  the  agent.  Perthes  has  shown  by  sections  that  a  wart  which  has  been 
properly  dosed,  frequently  with  but  one  treatment,  will  thereupon  undergo  a 
process  of  retrogression,  in  which  all  of  the  cells  forming  the  wart  become  horni- 


PARASITICAL  RELATIONS  OF  CANCER.  403 

fied,  mth  the  exception  of  those  of  the  deeper  or  germinal  layer;  and  these  promptly 
proliferate  and  produce,  not  a  new  ivart  as  before,  but  normal  new  skin  to  repair  the 
defect.  If  the  dose  is  not  sufficient  the  superficial  cells  will  undergo  hornification, 
the  wart  will  be  reduced  in  size,  but  the  cells  of  the  deeper  layer  will  again  pro- 
liferate and  produce  a  new  wart.  This  proves  conclusively  that  the  x-ray  does  not 
act  through  any  form  of  injury  to  the  cells  themselves.  It  removes  from  them  the 
tendency  to  proliferation  which  produces  the  wart,  and  leaves  behind,  in  the  necessary 
cells  of  the  germinal  layer,  normcd  uninjured  cells  which  are  capable  of  producing 


Fig.  123. — Microphotograph.      X  260.      Last  Remnant  of  Epithelium  from  a  Tumor  Tjndergoing 
Spontaneous  Retrogr 

neiu  and  normal  skin.  As  it  is  the  fate  of  superficial  epithelial  cells  of  the  skin, 
when  their  period  of  utility  is  passed,  to  undergo  hornification,  the  process  of 
hornification  in  the  cells  of  the  wart  is  probably  secondary.  Once  their  ]3ower 
of  abnormal  proliferation  has  been  removed,  they  succumb  to  that  fate  for  which 
they  were  normally  intended,  which  is  hornification;  and  this  involves  all  of  the 
cells  of  the  wart  except  those  which  are  destined  to  resume  their  normal  functions. 

Characteristics  of  the  UxKxo'n'N  Stimulus  in  Cancer. 

The  observations  thus  far  accumulated  on  the  spontaneous  retrogression  of  tu- 
mors, the  retrogression  of  tumors  through  an  immune  agent,  and  the  direct  or  indi- 
rect activity  of  the  .r-ray  and  radium,  tend  to  show  that  in  these  agents  we  have 
a  means  of  removing  from  the  cancer  cell  the  x-factor.  If,  as  conceded  by  Orth, 
there  takes  place  at  the  margin  of  tumors  a  gradual  transformation  of  normal 
epithelial  cells  into  cancer  cells,  and  if,  by  the  action  of  immune  sera  and  the  x- 
ray,  we  can  again  reduce  these  cancer  cells  to  the  status  of  normal  cells,  it  seems 


404 


AMERICAN  PRACTICE  OF  SURGERY. 


almost  conclusivelj'  sho-n-n  that  there  can  be  added  to  a  normal  epithelial  cell  a 
factor  which  is  capable  of  endowmg  it  with  the  power  of  continuous  prolifera- 
tion, and  which  can  again  be  removed  from  it,  leaving  a  normal  epithelial  cell. 
This  normal  epithelial  cell,  it  is  true,  maj-  be  superfluous,  in  which  case  it  will 
undergo  processes  of  atrophy  and  removal  the  same  as  ma}'  take  place  in  any 
other  misplaced  normal  epithelial  cell.  But  if,  as  in  the  case  of  warts,  the  cell 
still  has  a  function  to  perform,  it  can  resmne  its  natural  proliferative  activit}' — 
an  activity  which  does  not  overstep  the  bounds  set  by  the  physiological  laws  of 
normal  life. 

It  has  been  suggested  that  the  miknown  factor  in  cancer  is  of  a  chemical 
nature.  No  less  an  authoritj'  than  Marchand  has  suggested  that  it  might  be 
some  toxin.    If  the  facts  in  the  case  are  considered,  it  is  obvious,  as  Clowes  has 


Fig.  124. — Microphotograph. 


X  260.     Alveolus  at  Margin  of  Tumor  Undergoing  Retrogression 
from  Serum  Treatment. 


shown,  that  this  is  impossible.  An  agent  which  is  capable  of  keeping  up  contin- 
uous proliferation  in  cancer  cells — which,  theoretically  speaking,  starts  with  one 
cell  and  passes  into  its  offsprmg  through  thousands  of  generations,  during  which 
time  the  number  of  cancer  cells  increases  indefinitely — must,  quantitatively 
speaking,  increase  in  bulk.  That  this  must  be  so  is  evidenced  by  the  fact  that 
this  factor  can  be  removed  and  must  be  removed  from  each  and  every  cancer 
cell  before  the  cell  undergoes  retrogression.  This  is  shown  to  be  the  case  in  ex- 
perunental  tumors  which  are  undergoing  retrogression  after  treatment  by  the  x- 
ray  or  through  the  acti-\-ity  of  sera.  The  changes  brought  about  by  either  of 
these  agents  is  foimd  to  be  most  marked  at  the  periphery  of  the  tumor,  and  it 
has  been  found  that  epithelial  cells  taken  from  the  centres  of  tvmiors  which  are 


PARASITICAL  RELATIONS  OF  CANCER.  405 

retrograding  at  the. margins  can  be  transplanted  and  will  produce  tumors, 
whereas  the  cells  at  the  margins  present  changes  which  show  that  this  would  be 
impossible.  Therefore,  the  agent  must  be  removed  from  each  and  every  cancer 
cell ;  and  as  this  agent,  although  present  in  the  beginning  in  but  one  or  two  cells, 
later  comes  to  occupy  a  bulk  of  cells  which  can  scarcely  be  estimated,  and  as, 
furthermore,  it  must  likewise  have  increased  rather  than  have  diminished  in 
activity,  it  must  certainly  also  have  increased  in  amount.  How  enormous  the 
proliferative  powers  of  even  a  small  mouse  tumor  may  be  is  indicated  by  the 
astonishing  figures  which  Ehrlich  has  published  in  connection  with  his  rapidly 
growing  tumor  No.  7.  He  has  estimated  that  this  tumor  is  now  growing  at  a 
rate  which  would  permit  of  its  being  carried  through  sixty  generations  in  one 
year.  As  the  tumor  is  now  giving  nearly  100  per  cent  of  increase,  he  estimates 
that  if  from  12  to  15  mice  were  used  for  each  transplantation,  within  one  week 
10  tumors  of  the  size  of  that  used  for  transplantation  would  be  produced.  From 
each  of  these  in  eight  days  10  more  could  be  produced,  so  that  in  the  third  gen- 
eration 1,000  tumors,  in  the  fourth  10,000  tumors,  and  so  on,  would  result.  If 
this  were  carried  to  the  sixtieth  generation,  it  would  represent  10"°  c.cm.  of  tu- 
mor if  each  tumor  weighed  but  1  gm.  In  the  course  of  one  year  this  would  lead 
to  a  bulk  of  tumor  which  is  scarcely  comprehensible.  It  represents,  according  to 
Ehrlich,  a  cube  the  edge  of  which  would  measure  1,000,000,000,000  kilometres — 
a  distance  which  it  would  require  light  105  years  to  traverse.  In  spherical  form 
it  would  represent  a  mass  with  a  diameter  890  times  greater  than  that  of  the 
sun,  and  a  volume  exceeding  that  of  the  sun  7x10"°.  If  the  agent  which  could 
keep  pace  with  this  tremendous  increase  in  bulk  were  a  toxin,  it  could  only  do 
so  by  reproducing  itself;  and  the  only  possible  mechanism  by  which  this  could 
be  brought  about  would  be  by  the  agent  acting  upon  the  protoplasm  of  the  new 
cell  in  such  a  manner  as  to  cause  it  to  produce  its  like.  No  chemical  agent, 
however,  with  which  we  are  acquainted,  toxin  or  otherwise,  and  which  is  capable 
of  bringing  about  a  reaction  in  living  protoplasm,  causes  this  protoplasm  to  pro- 
duce the  same  agent.  On  the  contrary,  the  protoplasm  produces,  in  all  cases 
thus  far  known,  an  agent  which  is  antagonistic  to  the  first — in  other  words,  some 
form  of  anti-body.  For  this  reason  it  is  impossible  to  conceive  of  any  chemical 
agent  endowed  with  the  power  to  fulfil  the  conditions  of  the  2;-factor.  We  are 
therefore  compelled  to  assmne  that  the  x-factor  must  be  some  agent  which  can 
reproduce  itself,  and  thus  far  the  only  agents  with  which  we  are  acquainted 
which  can  accomplish  this  are  living  agents.  Hence  the  most  rational  explana- 
tion of  the  miknown  factor  in  cancer  is  that  it  is  some  living  agent.  If  we  so 
wish  we  can  speak  of  this  agent  as  a  virus,  as  does  Borrel,  inasmuch  as  we  do 
not  know  its  specific  natvire.  Borrel  believes  that  there  is  an  infectious  factor  in 
cancer  as  yet  imdemonstrated,  and  that  it  is  in  all  probability  an  invisible  or 
ultra-microscopic  organism.  The  same  contention  has  been  made  in  the  case  of 
syphilis,  because  the  agent  was  unknown  (unless  the  recent  observations  of 


406  a:\ieric.\x  practice  of  surgery. 

Schaudinn,  and  of  many  others  confirming  it,  should  ultimately  show  that 
Spirochete  pallida  represents  a  phase  of  the  organism  of  syphilis);  and  it  is 
likewise  held  to  be  true  in  smallpox,  in  vaccinia,  and  in  other  diseases. 

SiGXIFICAXCE    OF    FlLTKATIOX    ExPERniEXTS. 

The  belief  that  the  contagious  factor  is  invisible  has  usually  been  based  upon 
filtration  experiments.  The  virus  of  sheep-pox  has  been  show-n  by  Borrel  to  pass 
through  the  Berkefeld  and  the  coarser  grades  of  the  Chamberland  filter.  This 
has  likewise  been  sho^Ti  to  be  the  case  with  vaccine  viinis.  The  question  arises 
as  to  whether  filtration  experiments  are  necessarily  an  evidence  of  an  ultra- 
microscopic  organism.  Borrel  furnishes  light  on  this  point.  In  his  filtration  ex- 
periments vnth  sheep-pox  he  discovered  that  when  he  diluted  the  vh-us  with  tap 
water,  after  four  daj's  there  developed  in  the  filtered  and  otherwise  sterile  viinis 
a  small  protozoon,  to  which  he  gave  the  name  Micromonas  Mesnili.  The  organ- 
ism when  in  its  largest  form  in  the  virus — it  is  of  course  impossible  to  affii-m  that 
the  organism  mider  other  conditions  does  not  possess  a  still  larger  phase — was 
three  or  fom-  microns  long  and  as  many  wide.  That  the  organism  in  question 
had  nothing  to  do  vrith  the  virus  was  shown  when  distilled  or  sterilized  water 
was  used  to  dilute  the  virus.  Borrel  fomid  that  his  organism  followed  the  same 
law  as  the  active  principle  of  the  virus;  that  is,  it  passed  through  the  filters 
through  which  the  virus  passed,  and  was  held  back  by  filters  which  were  proof 
against  the  passage  of  the  A'irus.  That  the  organism  passed  through  m  some 
practicallj^  invisible  spore  form,  and  then  developed  on  the  suitable  medimn  of 
the  wus,  was  sho'RTi  by  its  appearance  in  virus  only  after  four  days  and  the  im- 
possibility of  detecting  it  in  filtered  water  in  which  the  larger  forms  did  not  de- 
velop. Borrel  was  forced  to  conclude :  "  Le  passage  a  travers  un  filtre  n'miplique 
pas  forcement  I'idee  d'vm  microbe  invisible." 

It  must  be  noted  that  Borrel's  ]\licromouas  shows  as  its  largest  form  an  or- 
ganism considerably  smaller  than  the  larger  inclusions  of  vaccine,  variola,  and 
cancer.  However,  to  assume  that  because  the  spore  of  an  organism  is  sufficiently 
small  to  pass  thi'ough  a  certain  filter,  its  largest  form  would  be  within  a  certain 
Imiit  of  size,  is  not  justified  by  biological  knowledge.  Calkins  has  described  a 
protozoon,  LjTtnphosporidium  truttff,  the  spores  of  which  have  a  diameter  of 
one  and  one-half  microns  and  divide  into  six  sporozoites,  each  less  than  one-half 
a  micron  in  diameter.  Borrel  likewise  points  out  that  there  is  an  essential  differ- 
ence between  the  smaller  forms  of  motile  animate  parasites  and  bacteria  of  rela- 
tiveh'  the  same  dimensions.  The  fii'st  are  more  plastic  and  acconmiodate  them- 
selves to  the  pores  of  the  filter,  passmg  through  where  bacteria  are  held  back. 
In  all  probability  the  sporozoites  of  Lymphosporidium  truttte,  less  than  one-half  a 
micron  in  diameter,  would  pass  through  a  bacteria-proof. filter ;  and  yet  the  largest 
form  of  this  organism  is  a  multinuclear  amoeba  twenty-five  microns  in  diameter. 

It  will  be  noted  that  ilicromonas  j\lesnili  is  three  to  four  microns  long  and  as 


PARASITICAL  RELATIONS  OF  CANCER.  407 

many  wide.  The  Spirochgete  pallida  in  its  smallest  form  is  one-quarter  of  a 
micron  in  diameter  and  four  to  fourteen  loiig.  Becchi  has  shown  that  even 
large  protozoan  amoeba?,  twenty-five  microns  in  diameter,  may  pass  readily 
through  Berkefeld  bougies,  and  for  this  reason  it  is  desirable  to  eliminate  filtra- 
tion experiments  in  attempting  to  determine  the  relative  size  of  organisms. 
There  is  a  not  remote  similarity  between  the  subcutaneous  lesions  of  syphilis  and 
some  of  the  infectious  granulomata  and  even  sarcomata. 

Infectious  Venereal  Granuloma  of  the  Dog. 
In  this  connection  Bashford  has  recently  described  the  histological  character- 
istics of  an  inoculable  venereal  granuloma  found  in  dogs,  which  possesses  certain 
characteristics  of  a  malignant  tumor,  and  presents  still  others  which  leave  no 
doubt  that  it  is  an  infectious  process,  although  the  virus  or  organism  is  as  yet 
undetermined.  This  tumor  seems  to  be  almost  a  coimecting.  link  between  the 
infectious  granulomata  and  malignant  tumors.  It  is  common  in  the  dog,  is 
transmitted  by  coitus,  and  develops  in  the  subcutaneous  tissue  about  the  geni- 
tals. The  tumor  cells  are  polygonal,  with  scanty  granular  protoplasm  and  large, 
spherical  nuclei.  In  the  resting  stage  they  possess  one  large  nucleolus  and  a 
delicate  chromatin  reticulum.  Mitotic  division  is  common  in  the  nuclei,  and, 
although  the  type  is  commonly  bipolar,  multipolar  figures  are  not  vmusual.  The 
tumor  is  divided  up  into  lobules  by  delicate  connective-tissue  septa  containing 
fully  developed  capillaries.  Hemorrhages  are  frequently  found.  The  general 
appearance  closely  resembles  that  of  a  round-celled  sarcoma  with  a  parenchjona 
arranged  in  alveoli.  In  primary  tumors  (see  Fig.  125)  Bashford  shows  that  a 
transformation  of  the  connective-tissue  cells  into  timior  cells  can  be  demon- 
strated. This  is  only  apparent  where  the  rapid  growth  of  the  tumor  has  not  re- 
sulted in  pressure  upon  the  surrounding  structiu'es.  One  striking  feature  of 
the  tumor  is  that,  although  this  transformation  is  going  on  at  the  periphery,  the 
greater  portion  of  the  bulk  of  the  tumor  is  brought  about  by  proliferation  of  the 
tumor  cells,  in  this  way  closely  resembling  the  method  of  growth  of  a  true  malig- 
nant tumor.  In  the  later  stages  the  tumor  grows  almost  entirely  from  its  own 
resources.  The  primary  lesion  in  this  tumor  is  therefore  in  no  way  different 
from  that  of  a  primary  sporadic  carcinoma,  in  which  there  is  likewise  a  trans- 
formation, at  the  margin,  of  normal  cells  into  cancer  cells.  When,  however, 
this  tumor  is  transplanted,  its  true  characteristics  appear.  According  to  Bash- 
ford, when  the  tumor  cells  are  implanted  in  the  subcutaneous  tissues  of  a  new 
host,  all  of  the  implanted  cells,  instead  of  continuing  to  proliferate,  disintegrate, 
and  a  new  tumor  is  formed  by  the  action  of  the  specific  factor  upon  the  connec- 
tive-tissue cells  of  the  host.  Evidence  of  this  process  is  fomid  by  Bashford  at 
the  margin  of  newly  developing  nodules  after  implantation.  Inasmuch  as  Bash- 
ford believes  that  the  implanted  cells  all  disintegrate,  it  is  obvious  that  the  virus 
is  the  only  factor  which  persists. 


408  AMERICAN  PRACTICE  OF  SURGERY. 

All  attempts  to  determine  the  precise  nature  of  this  virus  have  thus  far  failed. 
Filtration  experiments  do  not  appear  to  have  been  carried  out  thus  far.  These 
tumors  frequently  grow  to  great  size  and  sometimes  undergo  spontaneous  retro- 
gression. In  transplantation  experiments  new  tumors  can  be  recognized  in  from 
eight  to  ten  days,  and  subsequently  they  attain  a  diameter  of  several  inches. 
Metastases  may  likewise  develop  in  the  mesentery  after  intrascrotal  inoculation, 
and  the  lymph  nodes  adjacent  to  large  growths  are  frequently  enlarged. 
The  disease  cannot  be  transmitted  to  the  cat,  rabbit,  guinea-pig,  or  mouse. 
Bashford  concedes  that,  in  its  histological  features,  local  mode  of  origin,  partial 
growth  from  its  own  resources  (in  the  later  stages  causing  pressure  on  surround- 
ing tissues  and  organs),  and  in  the  limitation  of  its  transmissibility  to  one  species, 


■•>  ©I        °  ''^    -?       >     »    H'lf 


r.i/  '   ^-'^-'-T  '.tt 


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^{^^  ^  ®  )J 


•«f.Sai-- 


Fig.  125. — Infective  Venereal  Tumor  of  Vagina  of  1  >"g.  I'riiuarv  growth  in  vagina.  Transfor- 
mation of  connective-tissue  corpuscles  into  tumor  cells.      X  350.      (Basliford.) 

it  closely  resembles  a  malignant  growth.  He  believes  that  its  invariably  infec- 
tive history,  the  transformation  of  the  surrounding  connective-tissue  corpuscles 
into  tumor  cells  even  in  fully  de^^'eloped  tumors,  its  artificial  transmission,  fol- 
lowing the  laws  of  such  granulomata  as  tubercle  or  glanders,  and  the  fact  that 
it  occurs  naturally  in  animals  before  sexual  maturity,  all  serve  to  distinguish  it 
from  true  malignant  tumors. 

These  objections,  in  the  light  of  the  facts  already  adduced,  are  not  very  con- 
vincing. On  the  other  hand,  we  have  shown  that  there  is  strong  evidence  of  an 
infection  in  the  primary  sporadic  tumors  of  the  mouse,  and  we  may  add  that 
many  authorities  concede  that  in  primary  tumors  there  is  a  transformation  of 
normal  epithelial  cells  into  malignant  epithelial  cells  at  the  margin  of  the  tumor. 
Furthermore,  the  fact  that  the  disease  occurs  naturally  in  young  animals,  which 


PARASITICAL  RELATIONS  OF  CANCER.  409 

is  likewise  true  of  sarcomata,  should  speak  rather  in  favor  of  an  analogy  to 
malignant  growths,  which  appear  oftener  in  old  age  than  otherwise.  The  one 
respect  in  which  they  appear  to  differ  essentially  from  malignant  tumors  is  that 
the  cells  do  not  appear  to  possess  the  power  of  limitless  proliferation.  It  would 
seem  that  in  transplantation  experiments  it  would  be  a  matter  of  great  difficulty 
to  determine  whether  or  not  all  of  the  implanted  cells  disintegrate,  and  the  es- 
sential point  in  which  these  tumors  appear  to  differ  from  malignant  tumors  seems 
to  be  in  the  transformation  of  the  normal  cells  of  the  host,  in  transplanted  tu- 
mors, into  tumor  cells.  The  transplanted  tumor  in  this  case  appears  to  repeat 
processes  which  are  found  in  the  development  of  sporadic  tumors  only,  and  as 
such  it  would  appear  that  this  tumor  should  in  the  future  be  the  source  of  much 
fruitful  investigation.  The  points  which  it  has  in  connnon  with  true  malignant 
tumors,  the  fact  of  its  invariable  infectivity,  and  the  undoubted  presence  of  an 
infective  factor,  should  throw  much  light  upon  the  much  more  elusive  factors  in 
malignant  tumors. 

Sticker,  who  has  carried  out  extensive  transplantation  experiments  with  a 
tumor  similar  to  the  one  described  by  Bashford,  and  who  has  carefully  com- 
pared those  transplanted  by  Smith  and  Washburn,  Wehr  (1888),  and  Geissler 
(1895),  arrives  at  the  conclusion  that  Bashford's  interpretation  of  these  tmnors 
is  not  correct,  and  that  they  are  genuine  round-celled  sarcomas.  In  this  he  is 
supported  by  Albrecht,  Bollinger,  Duerck,  von  Hansemami,  Kitt,  Luepke,  Orth, 
Ribbert,  Schmaus,  Schmorl,  Schuetz,  Arnold,  and  Weigert,  all  of  whom  exam- 
ined specimens  of  all  five  tumors  (Smith  and  Washburn,  Sticker,  Wehr,  Geissler, 
and  Bashford),  and  diagnosed  them  to  be  typical  round-celled  sarcoma. 

SUMMARY. 

The  following,  then,  are  the  arguments  which  have  been  adduced,  from  the 
modern  research  into  cancer,  in  favor  of  the  infectiousness  of  the  process  : 

1.  An  analogy  exists  between  certain  of  the  changes  in  the  epithelium  in  can- 
cer and  those  occurring  in  the  epithelium  in  certain  of  the  acute  exanthemata, 
notably  variola  and  sheep-pox,  Icnown  infectious  diseases. 

2.  The  almost  exclusive  appearance  of  cancer  of  the  breast  in  elderly  female 
mice  which  have  been  used  extensively  for  breeding  is  best  explained  by  the 
transference  of  some  infective  agent,  through  the  medium  of  indiscriminate 
nursing,  by  offspring  (Ehrlich). 

3.  Tumors  in  mice  are  almost  never  found  alone.  In  breeding  establishments, 
where  one  case  appears  it  is  always  accompanied  by  others.  Healthy  mice, 
brought  in  contact  with  mice  with  primary  tumors,  acquire  the  same  (Borrel). 

4.  The  reappearance  of  sarcoma  of  the  rat  in  a  cage  which  had  contained  rats 
inoculated  with  sarcoma  points  to  the  possibility  of  cage  infection  in  this  form  of 
cancer. 


410  .-OIERIC-IX  PRACTICE  OF  SURGERY. 

5.  A  gradual  transformation  of  normal  epitjielial  cells  into  cancer  cells 
occm's  at  the  margins  of  primary  cancers  (Orth). 

6.  The  continued  transplantation  of  mouse  timiors  increases  rather  than 
reduces  then*  Airulence.  Certain  mouse  tmaiors  imder  transplantation  have 
acquued  a  A-irulence  only  comparable  to  that  of  an  acute  infectious  process. 

7.  The  transformation  of  an  adenocarcinoma  into  a  sarcoma  (Elu-lich)  is 
most  easily  explained  by  assuming  the  transference  of  an  infective  factor  from 
the  epitheliiun  into  the  connective  tissue  of  the  stroma. 

S.  A  certain  nmnber  of  mice  are  shown  to  possess  a  natural  immunity  which 
prevents  inoculation  with  cancer.  Spontaneous  retrogression  of  cancer  in  mice 
is  accompanied  by  histological  appearances  which  show  that  the  epithelium  is 
not  primarity  injured,  but  that  the  stimulating  factor  is  removed.  Spontaneous 
retrogression  is  accompanied  by  a  type  of  acc[uired  immunity  which  prevents 
the  successful  reinoculation  of  the  anhnal,  and  under  favorable  conditions  this 
factor  appears  to  be  present  in  the  blood  and  behaves  not  unlike  the  known 
antitoxins  to  infectious  processes. 

9.  The  blood  of  spontaneously  recovered  mice,  when  added  to  cancer  mate- 
rial before  transplantation,  removes  from  it  the  power  of  continued  proliferation. 
There  is  no  evidence  of  cytolj'tic  action  (Clowes). 

10.  Tumors  retrograding  under  the  influence  of  the  .z'-ray  and  radium  present 
exactly  the  histological  picture  of  tiunors  spontaneously  retrograding.  The 
stimulating  factor  seems  to  be  removed  from  the  epitheliimi  through  the  aid  of 
the  immune  mechanism. 

11.  The  epithelial  cells  of  the  deeper  layers  of  warts,  after  successful  treat- 
ment with  the  .T-ray,  no  longer  proliferate  to  form  a  new  wart,  but  reproduce  nor- 
mal skin  (Perthes),  showing  that  the  stimulus  to  proliferation  has  been  removed 
and  that  there  remain  epithelial  cells  capable  of  normal  proliferating  function. 

12.  The  unknown  factor  in  cancer  is  apparenth'  added  to  normal  epithelium, 
from  which  it  can  be  removed,  leaving  normal  epithelimn.  Through  the  prolif- 
eration of  the  cells  of  the  cancer,  which  increase  enormously,  this  factor  must  of 
necessity  graduall}''  increase  in  amount.  The  increase  in  bulk,  through  trans- 
plantation in  mouse  tmnors,  is  associated  with  increased  wulence.  The  onlj' 
known  agent  which  can  fulfil  these  conditions  is  a  li\'ing  organism.  The  unkno\\"n 
factor  maj-  be  an  ultramicroscopic  organism,  or  one  that  is  simph'  midemon- 
strable.  Filtration  experiments  in  infectious  diseases  of  imkno'mi  etiology  are 
not  competent  to  throw  any  light  on  this  phase  of  the  subject. 

13.  Infectioios  venereal  granuloma  of  the  dog,  an  imdoubtedly  infectious 
tumor,  presents  certain  points  of  similarity  to  malignant  processes.  The  tu- 
mor grows  largely  through  karj-okinesis  of  the  tvunor  cells  which  are  derived 
from  the  connective-tissue  cells  of  the  host  (Bashford).  The  cells  do  not  appear 
to  possess  the  power  of  limitless  proliferation,  although  perhaps  this  is  not  cou- 
clasively  proven. 


PARASITICAL  RELATIONS  OF  CANCER.  411 


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412  .-LAIERICIN   PRACTICE  OF   SURGERY. 

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PART  II. 

COMPLICATIONS    AND    SEQUELiE. 


INFECTIONS  WHICH  SOMETIMES  OCCUR  IN  VARI- 
OUS SURGICAL  DISEASES  AND  CONDITIONS. 

By  PAUL  MONROE  PILCHER,  M.D.,  New  York. 


WOUND  INFECTIONS. 

Without  exception,  surgical  infection  is  due  to  bacterial  activity.  Bacteria 
however,  may  be  present  in  a  wound  without  giving  rise  to  inflammation.  The 
virulence  of  the  micro-organisms,  the  environment  in  which  they  find  themselves, 
the  ability  of  the  tissues  to  protect  themselves — these  and  many  other  factors 
influence  the  course  of  the  infection. 

A  freshly  made  wound,  presenting  crushed  and  partly  devitalized  tissue,  and 
a  cavity  filled  with  coagulated  blood  and  serum,  furnish  the  ideal  conditions 
for  the  development  of  an  infective  infiammation. 

It  is  generally  accepted  that  the  Staphylococcus  pyogenes  aureus  and  albus 
and  the  Streptococcus  pyogenes,  separately  or  associated,  are  in  most  cases  the 
infective  agents.  Many  other  bacteria,  however,  may  be  the  etiological  factors. 
Among  the  most  important  of  these  are  the  Bacillus  coli  communis.  Bacillus 
pyocyaneus,  Proteus  vulgaris.  Micrococcus  tetragenus.  Bacillus  of  Friedlander, 
Bacillus  typhosus,  the  Gonococcus,  Streptococcus  erysipelatis,  and  the  Pneumo- 
coccus.  Some  of  these  bacteria,  imder  ordinary  conditions,  do  not  produce  a 
suppurative  inflammation ;  on  the  contrary,  they  are  more  f recjuently  associated 
with  some  other  form  of  exudation,  but  under  special  circumstances  they  may 
produce  suppuration. 

The  presence  of  bacterial  activity  in  a  wound  gives  rise  to  inflammation, 
clinically  recognized  by  the  local  redness,  swelling,  heat,  and  pain,  and  the  oc- 
currence of  fever.  These  phenomena  must  necessarily  vary  according  to  the 
character  of  the  tissue  which  is  the  seat  of  the  inflammation.  Redness  would 
necessarily  be  absent  in  a  non- vascular  tissue,  while  heat  as  a  sign  of  inflamma- 
tion has  not  been  observed  in  many  of  the  viscera.  The  degree  of  swelling  and 
pain  varies  with  the  tissue  and  the  individual  attacked. 

These  signs  are  due  to  pathological  changes  in  the  vessels  and  tissues.  At 
first  there  is  an  active  dilatation  of  all  of  the  vessels  and  an  increase  in  the  rapid- 
ity of  the  flow  of  blood  through  the  tissues;  in  other  words,  a  hyperamia.  This 
gives  rise  to  the  redness  and  heat.  Following  this  there  are  a  passive  dilatation  of 
the  capillaries  and  veins  and  a  gradual  slowing  of  the  blood.  The  relative  num- 
ber of  white  blood  cells  is  increased,  more  especially  in  the  veins.    Gradually, 

415 


416  A^IERiaiN  PRACTICE  OF  SURGERY. 

more  or  less  complete  stasis  of  the  blood  current  takes  place,  and  the  white  blood 
corpuscles  migrate  through  the  walls  of  the  veins  and  capillaries,  completely 
surrounding  the  -avails  of  the  vessels,  and  pass  on  out  into  the  contiguous  tissue. 
In  the  more  severe  forms  there  is  also  a  diapedesis  of  the  red  blood  cells,  which 
is  held  to  be  a  passive  transudation.  The  swelling  is  due  to  the  fluid  which  is 
exuded  from  the  vessels  into  the  Ijonph  spaces  and  then  into  the  tissue  itself. 
In  inflammation  of  the  peritoneum  or  plem-a  the  exudate  passes  dhectly  into  the 
peritoneal  or  pleural  caATities.  This  exudate  varies  greatly  under  different  con- 
ditions. It  may  be  a  purely  serous  exudate,  but  more  frequently  it  is  a  sero- 
fibrinous exudate.  According  to  Councilman,  the  fibrin  is  formed  entirely  out- 
side of  the  vessels.  The  fibrinogen  contained  in  the  serous  exudate  is  converted 
into  fibrin  in  the  presence  of  a  ferment  produced  by  the  degenerated  cells.  The 
exudate  in  the  case  of  a  suppurative  inflammation  is  characterized  by  the  pres- 
ence of  a  certain  number  of  degenerated  leucocytes,  an  increase  in  the  amount 
of  albumin,  and  a  greater  degree  of  coagulabilitj''  (Hildebrand).  It  is  especially 
rich  in  cells.  This  form  of  exudate  is  frequently  met  with  on  the  surface  of 
wounds,  and  is  known  as  a  fibrinous  or  croupoiis  exudate.  It  is  generalljf  associ- 
ated with  superficial  necrosis.  Again,  in  suppurative  inflammations  the  produc- 
tion of  pus  cells  may  greatly  predominate,  and  small  ca^'ities  be  formed,  contain- 
ing the  pus  cells,  exudate,  and  necrotic  tissue,  and  thus  an  abscess  will  be  formed. 
In  such  cases  the  amount  of  fibrin  found  is  generally  relatively  small.  According 
to  Councilman,  the  immediate  effect  of  the  presence  of  growing  bacteria  in  a 
wound  is  the  production  of  an  area  of  necrosis  around  them.  Around  this  ne- 
crotic area  or  even  within  it  are  seen  many  leucocytes  of  the  polymorphonuclear 
variety.  They  form  a  definite  wall.  The  chemotactic  properties  of  the  necrotic 
tissue  and  the  bacterial  products  increase,  and  the  leucocytes  invade  the  necrotic 
mass.  The  central  mass  liquefies,  becomes  circumscribed  by  granulation  tissue, 
and  an  abscess  is  formed,  the  liquid  contents  of  which  are  kno'wn  as  pus.  T^lien 
the  infection  is  more  severe  there  is  often  a  diapedesis  or  even  a  true  exudation 
of  red  blood  cells,  and  we  have  the  heriiorrhagic  exudate,  which  almost  always 
signifies  a  necrotic  process.  Necrosis  alwaj^s  accompanies  a  suppurative  inflam- 
mation in  the  tissues,  and  consequently  there  is  a  loss  of  tissue.  If  this  is  super- 
ficial it  is  seen  as  an  idcer;  or,  if  confined  within  the  tissues,  it  forms  an  abscess. 
Always  at  the  periphery  of  a  suppurative  mflammation  granulation  tissue  is 
built  up. 

Suppm'ation  may  be  confined  to  the  surface  of  the  wound,  or,  beginning  in 
the  wound,  it  may  spread  rapidly  and  involve  not  only  the  adjacent  tissues,  but 
also  the  general  system. 

As  has  been  already  stated,  the  cause  of  suppm'ation  in  a  wound  is  bacterial 
activitj-.  Generallj',  the  bacteria  gain  entrance  by  direct  inoculation  of  the 
wound.  There  are,  however,  other  avenues  of  entrance.  It  has  been  conclu- 
sively demonstrated  that  imder  certain  conditions  bacteria  may  pass  through 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  417 

the  epithelium  covering  the  tonsils  and  gain  entrance  to  the  general  circulation. 
This  is  also  true  of  the  mucous  membranes  lining  the  intestinal  and  respiratory 
tracts.  These  facts  are  of  special  interest  in  explaining  those  cases  of  infection 
in  which  there  has  been  no  discoverable  external  wound  or  those  in  which  an  in- 
jury, such  as  a  simple  fracture,  becomes  infected  and  gives  rise  to  an  extensive 
suppurative  process. 

It  must  be  remembered  that  not  all  bacteria  which  gain  access  to  the  wound 
bring  about  suppuration.  In  the  first  place,  they  must  find  a  proper  medium  for 
their  activities  and  development.  It  is  true,  too,  of  some  bacteria  that  they 
cause  suppuration  in  one  animal  and  not  in  another;  also  some  bacteria  acting 
alone  are  non-pathogenic,  but  when  associated  with  other  forms  of  bacteria  they 
become  actively  pathogenic.  Having  gained  access  to  the  wound,  they  may  ac- 
tively proliferate  and  invade  the  surrounding  tissues  or  pass  directly  into  the 
lymph  or  blood  streams  and  bring  about  a  general  infection. 

The  next  question  of  importance  is.  How  do  the  bacteria  cause  injury  to  the 
tissues  f  As  a,  result  of  exliaustive  researches,  the  conclusion  has  been  reached 
that  the  phenomenon  is  fundamentally  a  chemical  process.  The  bacteria  them- 
selves secrete  ferments  which  act  directly  upon  the  tissues,  exerting  a  peculiar 
digestive  action  upon  them.  They  further  assimilate  certain  substances  from 
the  surrounding  tissues  and  excrete  others.  These  latter  assimilation  products 
are  chiefly  ptomains,  such  as  putrescin,  sepsin,  and  cadaverin,  and  are  poison- 
ous; so  also  are  the  bacterial  proteins  and  toxalbumins  (Hildebrand).  These 
poisons  act  locally  upon  the  tissues,  causing  necrosis,  and  the  combined  resorp- 
tion into  the  system  of  the  products  of  decomposition  and  the  bacterial  toxins 
gives  rise  to  the  constitutional  intoxication. 

Of  all  the  pus-producing  bacteria,  the  Staphylococcus  pyogenes  aureus  and 
albus  and  the  Streptococcus  pyogenes  are  the  most  frec^uently  met  with.  The 
staphylococcus  is  most  often  the  cause  of  localized  suppurative  processes,  such 
as  furunculosis,  carbmicles,  localized  abscess,  acute  osteomyelitis  and  periostitis, 
pustular  skin  diseases,  empyema,  etc.  The  streptococci  are  seldom  found  in 
these  conditions,  but  are  found  more  frequently  in  the  phlegmonous  inflamma- 
tions. When  these  cocci — either  separately  or  in  combination — are  introduced 
into  a  wound  in  sufficient  numbers,  they  give  rise  to  a  suppurative  inflamma- 
tion. The  local  tissue  which  is  infected  helps  to  limit  the  disease  by  bviilding 
up  granulation  tissue.  The  vascular  system  supplies  the  fibrinogen  and  the  leu- 
cocytes. The  leucocytes  invade  the  inflammatory  tissue,  and,  acting  as  pha- 
gocytes, help  to  limit  the  growth  of  the  cocci  and  eventually  to  destroy  them. 
It  is  questioned  by  many  whether  the  leucocytes  act  as  true  phagocytes ;  be 
this  as  it  may,  they  certainly  play  an  active  part  in  inhibiting  the  spread  of  the 
cocci.  There  are  also  in  the  blood  a  number  of  other  substances,  which  are  di- 
rectly antagonistic  to  the  bacteria  and  their  products.  Two  of  these,  agglutinin 
and  bacteriolysin,  are  produced  in  the  spleen,  bone-marrow,  and  lymph  nodes, 
VOL.  I. — 27 


418  a:merican  practice  of  surgery. 

and  seem  to  act  by  paralyzing  the  bacteria  and  preparing  them  for  the  attack 
of  the  alexins.  Alexin  is  produced  in  the  blood  itself,  and  is  deadly  to  the  cocci. 
There  is  also  present  in  the  blood  serum  a  much  more  potent  factor,  viz.,  anti- 
toxin, which  is  a  true  bactericide. 

The  protective  forces  of  the  body  may  temporarily  limit  the  advance  of  a 
suppurative  inflanmiation  without  enthely  stamping  it  out.  An  example  of  this, 
may  be  occasionally  fovmd  in  bone  abscesses,  which  subside  after  a  period  of 
considerable  activity,  remain  cjuiescent  for  years,  and  then  suddenly  give  rise  to 
severe  symptoms.  The  infectious  agents  in  such  cases  are  almost  always  staphy- 
lococci. 

Another  micro-organism  of  frequent  occurrence  in  suppurative  processes  is 
the  Bacillus  pyocyaneus.  Many  authors  maintain  that  it  exists  simply  as  a 
saprophyte  on  the  skin,  and  that,  acting  alone,  it  does  not  cause  suppm'ation. 
Other  writers,  however,  believe  that  imder  certain  conditions  it  must  be  classed 
as  a  pyogenic  bacterium.  We  do  know  that,  when  associated  with  streptococcic  or 
staphylococcic  infections,  it  becomes  active  and  gives  rise  to  a  peculiar  exudate, 
called  green  or  blue  pus.    It  shows  its  blue  color  only  in  the  presence  of  oxygen. 

Wlien  pyogenic  bacteria  become  active  in  the  tissues  of  the  body,  various 
types  of  inflammation  may  follow.  If  the  process  is  confined  within  the  tissues 
an  abscess  results,  which  may  spread  or  remain  localized.  If  a  general  infiltra- 
tion of  the  tissues  takes  place,  it  is  known  as  a  phlegmonous  inflammatioji.  "\^^ien 
the  abscess  is  superficial  and  opens  on  the  skin,  it  is  called  thereafter  an  ulcer. 
In  such  a  condition  there  is  always  a  loss  of  substance,  exposing  the  deeper 
tissues.  Certain  localized  deep-seated  inflammations  of  the  skin  are  termed 
furuncles  or  boils.  Cellulitis  of  the  soft  parts  of  the  fuigers  or  toes  are  called 
felons,  or  paronychice. 

In  all  of  these  conditions  the  ordinary  phenomena  of  inflammation  are  evi- 
dent in  varying  degrees.  The  constitutional  s}nQaptoms  are  sometimes  marked, 
but  thej'  rapidly  subside  upon  removal  of  the  local  cause. 

Infection  complicating  the  healing  of  a  wound  maj'  manifest  itself  m  various 
ways.  It  may  cause  a  simple  inflammation  and  active  suppuration  may  not  oc- 
cur, or  a  most  active  and  virulent  suppurative  or  gangrenous  inflammation  may 
result.  The  process  may  be  limited  to  the  wound  and  its  immediate  neighbor- 
hood, or  it  may  be  progressive  and  inA'oh^e  large  areas. 

SIMPLE  INFECTION. 

When  a  recent  womid  is  infected,  it  may  not  show  signs  of  inflammation  until 
the  second  or  third  day.  If  the  woimd  has  been  sutured,  the  constitutional 
symptoms  may  be  the  first  evidence  of  the  infection.  The  patient  complains  of 
headache  or  a  feeling  of  general  malaise.  There  may  be  anorexia  or  even  nausea. 
Unless  the  uifection  is  extensive,  vomiting  does  not  generally  occur.  The  most 
constant  sjmaptom  is  fever.    At  first  there  is  little  to  differentiate  this  fever  from 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE. 


419 


the  ordinary  aseptic  wound  fever  which  almost  always  is  noticed  in  the  healing 
of  extensive  wounds,  especially  where  there  is  much  loss  of  blood  or  destruction 
of  tissue.  Such  fevers  usually  subside  on  the  second  or  third  day  following  the 
injury  to  the  tissues.  The  fever  accompanying  an  infection,  however,  does  not 
subside.  At  first  the  body  temperature  may  not  be  very  high,  but  gradually  it 
increases,  until  on  the  third  or 
fourth  day  it  may  register  103°  F. 
or  higher.  The  pulse  varies.  Usu- 
ally there  is  a  corresponding  in- 
crease, but  at  first  it  may  not  be 
marked.  An  examination  of  the 
wound,  if  it  be  sutured,  will  show 
a  redness  and  oedema  along  the 
suture  line.  If  the  infection  be 
deep-seated  there  may  be  no  su- 
perficial signs,  but  palpation  will 
demonstrate  induration  and  ten- 
derness. The  patient  may  com- 
plain of  local  pain.  When  the 
infection  is  extensive  all  the 
symptoms  of  a  suppurative  in- 
flammation are  present.  If  the 
wound  is  an  open  one  there 
will  be  noted  an  increase  in  the 
amoimt  of  the  secretion  which  it  furnishes.  At  first,  this  secretion  is  sero- 
sanguineous,  but  later  it  becomes  purulent.  The  edges  of  the  wound  become 
swollen  and  oedematous,  and,  as  the  infection  spreads  into  the  connective 
tissue  and  between  the  muscular  septa,  the  usual  symptoms  of  a  phlegmonous 
inflammation  develop.  If  the  infected  area  is  not  incised  or  opened  it  may 
become  localized,  being  circumscribed  by  granulation  tissue — in  other  words, 
an  abscess  may  form;  or  the  infection  may  rapidly  spread  and  give  rise  to 
an  extensive  phlegmonous  inflammation.  Again,  the  toxins  and  the  micro- 
organisms may  be  rapidly  absorbed  and  give  rise  to  septicaemia  or  pyeemia. 
Usually,  when  the  process  is  discovered  early  and  free  drainage  is  provided, 
combined  with  the  proper  antiseptic  treatment  of  the  wound,  the  signs  and 
symptoms  of  inflammation  gradually  subside  and  the  wound  heals  by  granula- 
tion. If  the  superficial  portions  of  the  woimd  heal  first,  retention  of  the  secre- 
tions and  purulent  exudate  may  occiu-,  and  then  the  constitutional  sjntnptoms 
due  to  the  absorption  of  the  toxins  will  again  appear.  During  the  course  of 
healing  of  such  infective  processes,  if  the  infection  be  deep-seated,  sinuses  and 
fistulce  often  result,  and  these  do  not  heal  until  all  of  the  necrotic  or  infected 
tissue  has  come  away. 


DISEASE 

1 

^ 

3 

4 

5 

6 

7 

8 

'■"• 

P.-. 

..„. 

'■"■ 

«-"• 

'■"■ 

..„. 

P.„. 

.M. 

P.M. 

..„. 

P.„. 

.„. 

P,„. 

... 

P.». 

107° 

106° 

105° 

c   104° 

X 

< 

t  103 

I  ''' 

S  101° 
s 
j^  100 

99° 

98° 

97° 

e 

t- 

° 

15 

3 

A 

i 

2 

i 

/ 

/^ 

J 

\J 

A 

I 

^ 

y 

/" 

\ 

/\ 

/ 

/" 

s/ 

V 

/^ 

\ 

/ 

Fig.   126. — Temperature  Chart  of  a  Case  of  Infected 
Wound  Following  Operation. 


420 


MIERICAN  PRACTICE  OF  SURGERY. 


ACUTE  SEPTIC  PHLEGMONA. 

Aside  from  the  simple  wound  infections  and  suppm-ative  plilegmona  which 
tend  to  remain  more  or  less  localized  or  are  easilj^  controlled  by  treatment,  there 
are  a  number  of  acute  infective  processes  which  originate  in  a  woimd  and  rapidly 
and  progressively  spread,  often  giving  rise  to  most  alarming  sJ^xlptoms.  The 
mildest  form  of  this  tjrpe  of  infection  is  the  so-called  progressive  phlegmonous  in- 
filtration, which  spreads  rapidly  from  the  seat  of  the  original  infection,  mvolvmg 
the  connective  tissue,  the  intermuscular  septa,  the  fascia,  and  the  tendon  sheaths, 
without  leading  to  localized  pus  formation.  It  is  most  frequently  seen  in  com- 
pound fractures  of  the  extremities  or  in  extensive  crushing  injuries.  The  first 
symptoms  usually  appear  within  three  or  four  daj'S  after  the  injm-y.    There  is  a 


PULSE 

TEMPERATURE  (FAHR.) 

s    g_    s    i    g    i    s    1    i    §    § 

^ 

\ 

INJUR 

■^ 

- 

■> 

> 

<^ 

< 

» 

■^ 

" 

> 

i 

CL_ 



CHILL 

. 

'^ 

•^ 

' — ■ 

~7 

? 

( 

< 

MULT 

PLE 

^ 

) 

> 

INCIS 

ONS 

N 

< 

^ 

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i 

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INCIS 

ON 

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% 

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Fig.  127. — Temperature  and  Pulse  Curves  of  a  Case  of  Acute  Septic  Phlegmon  foUo-n-ing  Extensive 
Injury  of  Foot. 

chill,  accompanied  by  a  rapid  rise  in  temperature  and  a  rapid  pulse.  There  is  a 
foul-smelling  discharge  from  the  wound  and  a  rapidly  extending  oedema.  The 
tissues  are  infiltrated  with  a  foul-smelling  sero-purulent  exudate,  which,  if  not 
relieved,  results  in  extensive  necrosis  and  diffuse  suppuration.  The  constitu- 
tional symptoms  are  marked. 

Acute  Purulent  OiIdeil^. 

Another  form  of  the  same  type  of  infective  processes  is  the  acute  purulent 
oedema,  first  described  by  Pirogoif .    The  original  wound  may  have  been  slight,  or 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE. 


421 


DAY  OF 
DISEASE 

1 

2 

3 

4 

5 

6 

7 

A.«. 

P.«. 

-■ 

..«. 

••"■ 

..«. 

A.„. 

p.„. 

..„. 

P.M. 

..M. 

p.„. 

A.„. 

'•"• 

107° 

106° 

105° 

2  104° 

I 

< 

5  103 

^  ioa° 
< 

S  101° 

^  100 
99° 
98° 
97° 

i 

£ 

IS 

\ 

/ 

^ 

/ 

A 

V 

N 

J 

\ 

K 

/  \ 

k/ 

/ 

'\ 

r 

J 

\l 

/ 

y 

/ 

/ 

it  may  follow  or  complicate  extensive  crushing  injm-ies.  The  progress  of  the 
infection  is  rapid  and  virulent.  Within  from  twelve  to  twenty-four  hoiu-s  after  the 
injury  the  part,  usually  an  extremity, 
becomes  I'apidly  swollen  and  oedema- 
tous.  The  sero-sanguineous  discharge 
from  the  wound  becomes  sero-puru- 
lent  and  is  very  offensive.  Marked 
constitutional  symptoms  arise.  The 
body  temperature  is  high  and  the 
pulse  rate  rapid.  The  swelling  rapidly 
increases.  If  the  tissues  are  incised 
they  will  be  found  to  be  everywhere 
infiltrated  with  cloudy  fluid.  Portions 
of  the  tissues  are  already  necrotic, 
despite  the  short  duration  of  the 
disease.  The  odor  of  the  secretions 
is  most  foul.  The  Ijrmphatics  are 
extensively  involved.  In  a  few  days 
multiple  suppurative  foci  develop 
throughout  the  tissues.  The  abscess 
cavities  are  filled  with  offensive  pus, 
necrotic  tissue,  and  frequently  foul- 
smelling  gas.  Often  an  entire  extremity  is  involved  in  the  process.  The  disease 
generally  terminates  in  a  fatal  septicemia. 

Gangrene  Foudroyante. 

The  gangrene  foudroyante,  first  described  by  Maisonneuve,  is  closely  allied  to 
the  process  which  has  just  been  described.  It  most  frequently  follows  a  bone 
injury,  and  has  often  been  known  to  follow  a  crushing  injury  of  the  foot  or  leg. 
It  is  characterized  by  the  progressive  character  of  the  infection,  the  rapid  course, 
the  gangrenous  destruction  of  the  tissues,  and  the  production  of  gas  abscesses 
and  a  spreading  emphysema  (Hildebrand).  The  cause  of  the  infection  is  the 
Bacillus  of  malignant  oedema  (Koch). 

In  such  cases  the  extremity  swells  rapidly  and  soon  gives  evidence  of  a  spread- 
ing emphysema.  The  secretion  from  the  wotmd  is  sero-sanguineous  and  scanty. 
The  extremity  shows  an  advancing  dusky  oedema.  In  twenty-four  hours  the 
entire  limb  may  be  involved.  The  skin  crackles  when  touched  (Spencer).  The 
vems  appear  as  bluish  stripes  on  the  brownish-red  skin.  The  constitutional 
symptoms  vary.  The  body  temperature  may  not  be  high  or  we  may  have  a  tj^p- 
ical  septic  curve.  Frequently  diarrhoea  and  involimtary  evacuations  of  the  blad- 
der and  rectum  occur.  The  patient  is  restless.  The  pulse  is  rapid.  Commencing 
gangrene  is  seen.     Incisions  show  multiple  abscesses  containing  pus  and  foul- 


FiG.  128. — Temperature  Chart  of  a  Case  of 
Acute  Purulent  OEdema,  which  Terminated 
Fatally. 


422  AMERICAN  PRACTICE  OF  SURGERY. 

smelling  gas.     The  gangrene  extends  rapidly.    The  body  temperature  gradually 
falls,  sometimes  becoming  subnormal,  and  death  follows. 

The  prognosis  is  bad.  Death  generally  occurs,  but  cases  of  recovery  have 
been  reported.  The  treatment  consists  of  multiple  incisions  and  continuous 
irrigations  or  early  amputation. 

Lymphangitis. 

Infections  may  spread  from  the  original  focus  and  involve  the  lymph  chan- 
nels, and  an  endolymphangitis  or  perilymphangitis  be  set  up.  It  may  further 
reach  the  lymph  nodes  and  cause  a  Ijmiphadenitis.  The  consideration  of  this 
form  of  infection  will  be  taken  up  in  the  article  devoted  to  the  Diseases  of  the 
Lymphatics. 

Local  Infections  of  Granulating  Wounds. 

There  is  a  certain  form  of  infection  which  attacks  not  only  recent  wounds, 
but  also  wounds  which  are  already  covered  with  healthy  granulations.  This 
disease  is  commonly  known  as  hospital  gangrene.  The  etiology  as  yet  is  uncer- 
tain. Numerous  micro-organisms  have  been  found,  but  no  particular  one  has 
been  isolated  which  is  known  to  bring  about  the  disease.  The  first  manifesta- 
tions are  a  progressive  infiltration  and  a  coagulation  necrosis  of  the  granulations, 
the  process  spreading  rapidly  at  the  periphery  of  the  ulcer  and  at  the  same  time 
penetrating  deeply  into  the  tissues.  The  disease  is  further  characterized  by  a 
gangrenous  destruction  of  the  inflamed  tissue.  The  first  symptoms  are  entirely 
local,  and  the  disease  spreads  by  attacking  the  contiguous  tissues. 

Three  forms  have  been  described:  (1)  The  croupous  or  diphtheritic;  (2)  the 
ulcerating;  (3)  the  pulpous  form.  The  first  is  characterized  by  the  formation  of 
a  pseudo-membrane  on  the  surface  of  the  granulations,  underneath  which 
extensive  necrosis  and  gangrene  of  the  tissues  rapidly  develop.  The  surround- 
ing tissues  are  not  much  inflamed.  The  second  form  is  characterized  by  a  rap- 
idly spreading  ulcer,  with  necrosis  of  the  underlying  tissues  and  a  copious,  foul- 
smelling  discharge.  The  third  form  is  the  most  virulent.  There  is  a  rapid 
puffing  up  or  swelling  of  the  tissues.  Hemorrhages  take  place  within  the  granu- 
lations, and  they  undergo  a  purulent  necrosis,  followed  by  gangrene  and  a 
separation  of  the  entire  mass.  The  surrounding  tissues  are  markedly  oedem- 
atous  and  inflamed,  and  the  ulcerated  surfaces  are  exquisitely  tender.  In 
all  of  these  forms  the  process  spreads  rapidly,  attacking  and  destroying  every- 
thing in  its  path. 

The  constitutional  symptoms  are  marked,  and  present  all  the  phenomena  of 
a  general  systemic  intoxication. 

The  prognosis  is  grave.  It  naturally  varies  with  the  form  of  the  disease,  the 
pulpous  form  being  the  most  fatal.  In  the  Civil  War  in  this  country  the  mortal- 
ity was  45.6  per  cent. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  423 

SEPTICEMIA. 

The  term  septic£emia  is  no  longer  accepted  in  tlie  sense  of  its  literal  transla- 
tion, but  nevertheless,  on  account  of  long  usage  and  general  acceptance,  it  is  still 
so  employed.  It  is  not  possible  to  define  it  pathologically,  because  its  limits  are 
not  fixed.  We  accept  it  more  as  a  word  which  is  suitable  for  designating  the 
degree  or  the  severity  of  certain  general  intoxications  and  infections.  Clinically 
we  speak  of  an  infection  as  local  when  the  predominant  symptoms  are  due  to 
the  local  disturbance,  the  systemic  manifestations  appearing  as  secondary.  In 
the  case  of  an  abscess  which  is  confined,  the  surrounding  walls  exert  a  certain 
amount  of  pressure  upon  the  contained  pus,  and  resorption  of  the  toxic  ma- 
terials takes  place.  Frequently  bacteria  as  well  are  found  in  the  blood,  and 
we  practically  have  a  septicaemia.  When  the  abscess  is  opened  and  the  tension 
is  relieved,  the  general  symptoms  subside  and  the  infection  is  then  merely  local. 
If,  however,  upon  evacuation  of  the  pus,  the  general  symptoms  continue  and 
we  have  a  systemic  intoxication,  we  speak  of  it  as  a  septicaemia  or  a  general 
septic  infection. 

Gussenbauer  has  defined  septicaemia  as  a  "general  disease  of  the  body,  which 
results  from  the  introduction  into  the  circulation  of  the  products  of  decomposi- 
tion, and  which  is  characterized  by  definite  changes  in  the  blood,  a  typical  suc- 
cession of  inflammatory  processes,  and  a  continuous  fever,  together  with  peculiar 
nervous  symptoms  and  critical  discharges."  The  extensive  researches  of  Ogsten, 
Rosenbach,  Doyen,  von  Eiselsberg,  and  others  have  taught  us  that  the  general 
systemic  disease  known  as  septicaemia  depends  upon  the  introduction  of  patho- 
genic, especially  pyogenic,  micro-organisms  into  the  general  circulation.  How- 
ever, there  is  another  general  intoxication,  known  as  sapraemia,  or  septic  intoxi- 
cation. This  intoxication,  which  results  from  the  absorption  of  the  products 
of  putrefaction,  is  so  closely  allied  clinically  to  true  septicaemia  that  it  must  be 
considered  in  connection  with  it. 

Sapraemia  is  a  septic  intoxication  or  toxjemia,  due  to  the  absorption  of  tox- 
ins formed  by  the  bacteria  of  putrefaction.  It  should  not  be  confounded  with 
the  so-called  aseptic  wound  fever,  which  results  from  the  absorption  of  the 
products  of  aseptic  tissue  necrosis,  and  which  gives  rise  to  a  systemic  intoxica- 
tion. In  sapraemia  we  have  a  definite  pathological  lesion;  that  is,  the  infection 
of  necrotic  tissue  with  putrefactive  bacteria.  Among  the  most  important  of 
these  micro-organisms  may  be  mentioned  the  Proteus  vulgaris.  Locally,  as  a 
result  of  the  putrefactive  processes,  certain  ptomains  are  elaborated,  which  are 
absorbed  and  bring  about  a  general  septic  intoxication. 

Symptoms  and  Diagnosis. — The  symptoms  which  develop  are  those  of  a  local 
putrefactive  process  combined  with  the  constitutional  symptoms  of  a  ptomain 
poisoning  which  is  gradually  progressive,  which  acts  as  a  depressant  on  the  ner- 
vous system,  and  which  gives  rise  to  considerable  fever.    The  local  focus  of  in- 


42i 


AMERICAN   PRACTICE   OF   SURGERY. 


fection  is  generally  unmistakable.  Frequently  the  interior  of  the  uterus  is  the 
seat  of  the  disease.  Following  childbirth,  there  is  an  infection  of  the  secund- 
ines  retained  within  the  uterus;  the  foul  discharge  and  the  febrile  movement 
direct  our  attention  to  the  condition,  and  the  diagnosis  is  then  easy.  More  fre- 
quently, large  masses  of  gangrenous  or  sloughing  tissue  in  a  wound  undergo 
putrefaction,  and  the  foul  odor  of  the  putrefying  tissues,  as  well  as  the  visual 
picture,  establishes  the  diagnosis.  The  constitutional  symptoms  are  seldom 
initiated  by  an  actual  chill,  but  more  frequently  the  patient  complains  of  a  head- 
ache, loss  of  appetite  and  general  malaise.  While  there  may  not  be  an  actual 
chill  there  is  usually  a  sensation  of  chilliness.  At  first  the  body  temperature 
rises  to  99.5°  or  100°  F.  The  following  morning  it  may  again  be  normal.  On 
the  afternoon  of  the  second  day  the  temperature  becomes  higher,  and  we  have  a 


DISEASE 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

.... 

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,.M. 

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P.M. 

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P.„. 

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P.M. 

».M. 

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..M. 

p.„. 

,.„. 

P.M. 

.... 

P.„. 

107° 
10G° 

lOo' 
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I 

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f   102° 

£  101° 

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99° 

98° 

97° 

A 

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/ 

/ 

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Fig.  129. — Temperature  Curve  of  a  Case  of  a  Mild  Grade  of  Saprajmia. 

continuous  fever  with  slight  remissions,  its  severity  being  directly. proportionate 
to  the  extent  of  the  local  putrefactive  process.  If  the  diseased  tissue  is  not  re- 
moved, the  headache  becomes  more  intense,  the  body  temperature  rises,  vomiting 
and  diarrhoea  occur.  An  examination  of  the  blood  will  show  degenerative  changes : 
in  the  more  severe  cases  poikylocytosis  and  diminution  in  the  number  of  red 
blood  cells,  and  a  moderate  leucocytosis.  The  pulse,  at  first  soft  and  compress- 
ible, becomes  rapid  and  weak.  The  tongue  is  furred  and  dry.  The  urine  is 
scanty.  Gradually  the  poison  overcomes  the  nervous  system,  delirium  follows 
restlessness,  and  coma  develops.  Mictm'ition  and  defecation  become  involun- 
tary. The  pupils  become  dilated,  the  patient  is  covered  with  a  cold,  clammy 
perspiration,  the  pulse  becomes  irregular  and  feeble,  and  death  occurs.    In  some 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  425 

cases  the  disease  is  marked  by  intense  gastro-intestinal  symptoms.  The  vomit- 
ing and  purgmg  may  be  so  severe  that  the  case  may  simulate  cholera.  In  the 
milder  cases,  in  which  the  amount  of  tissue  acted  upon  by  the  saprophytes  is 
small,  the  disease  soon  rmis  its  course  and  subsides. 

Prognosis. — In  uncomplicated  cases  the  prognosis  is  good,  because  the  dis- 
ease is  easily  recognized,  and  prompt  treatment  is  usually  followed  by  a  rapid 
subsidence  of  the  symptoms.  The  great  danger  lies  in  the  possibility  of  second- 
ary infection,  which,  when  it  occurs,  generally  gives  rise  to  a  severe  form  of  sep- 
tic infection. 

Treatment. — Prophylactic  measures  in  this  condition  are  of  paramoimt  im- 
portance; they  comprise  the  removal,  wherever  possible,  of  all  necrotic  tissue 
which  is  liable  to  undergo  putrefaction,  or,  if  this  be  not  possible,  the  steriliza- 
tion (through  chemical  means)  of  the  necrotic  tissue  and  the  prevention  of  in- 
fection. When  the  disease  is  established,  prompt  measures  must  be  taken  to 
remove  all  of  the  infected  material  and  to  prevent  a  reaccumulation.  The  gen- 
eral systemic  treatment  will  be  discussed  under  the  treatment  of  septicajmia  in 
general. 

Septicsemia. — Under  this  head  we  will  consider  that  septic  infection  of  the 
entire  body  which  is  brought  about  by  various  kinds  of  bacteria,  and  which  gives 
rise  to  the  symptoms  of  a  constitutional  intoxication  without  the  clinical  signs 
of  metastases.  This  includes  the  various  forms  of  septiesemia  designated  as 
toxaemia,  toxintemia,  pyotoxinsemia,  bacteritemia,  and  pyosepticsemia. 

Etiology. — What  has  been  said  concerning  the  relation  of  bacteria  to  the  sup- 
purative inflammations  is  also  applicable  to  septicaemia.  There  is  no  specific 
micro-organism.  Unquestionably  the  staphylococci  and  the  streptococci  play 
the  most  important  role.  We  may  have  more  than  one  variety  of  bacteria  pres- 
ent in  the  same  case,  as  in  double  infection,  or  we  may  have  a  secondary  infec- 
tion. It  is  still  doubtful  whether  the  bacteria  which  gain  entrance  to  the  general 
circulation  increase  and  produce  their  toxins  in  the  blood.  Brunner  holds  that 
an  acute  mycosis  never  is  met  with  in  the  human  blood,  and  he  believes  that 
there  never  occurs  any  marked  growth  of  bacteria  in  the  blood.  He  further 
maintains  that  the  micro-organisms  are  prone  to  collect  in  the  parenchymatous 
organs,  and  that,  in  the  acute  cases,  they  set  up  metastatic  processes,  which, 
however,  remain  microscopically  small,  the  duration  of  the  disease  being  too 
short  to  develop  macroscopic  foci  or  to  manifest  itself  by  any  clinical  evidence. 
The  majority  of  investigators  believe,  however,  that  the  bacteria,  after  gain- 
ing entrance  to  the  blood,  increase  and  elaborate  their  poisons  in  the  blood, 
and  then,  independently  of  any  other  suppiu-ative  foci,  may  cause  death.  In 
certain  severe  local  infections  it  has  already  been  noted  that  the  staphylo- 
cocci and  streptococci  produce  very  poisonous  toxoproteins  and  toxalbumins, 
and  that  these  poisons  may  be  reabsorbed  and  give  rise  to  septicaemia.  It  has 
also  been  shown  that  in  such  cases  numerous  micro-organisms  reach  the  circu- 


426  AMERICAN  PRACTICE  OF  SLTRGERY. 

lation,  but  the  action  of  the  reabsorbed  toxins  is  so  rapid  and  severe  that 
they  produce  the  symptoms  of  the  disease  before  the  micro-organisms  have 
had  time  to  increase  and  become  active.  This  form  of  sepsis  is  called  toxincemia. 
In  other  cases  the  bacteria  themselves  rapidly  reach  the  circulation,  and  there 
increase  and  produce  toxins,  and  we  have  a  hactericemia. 

The  question  naturally  arises.  How  do  the  toxins  and  the  bacteria  gain  en- 
trance to  the  blood?  In  the  rapidly  fatal  cases  it  seems  most  probable  that  they 
pass  directly  into  the  lymph  spaces  and  are  in  this  manner  thrown  into  the  gen- 
eral circulation.  In  other  cases,  again,  they  must  first  penetrate  the  granulation 
tissue,  and,  passing  along  the  main  lymph  channels  and  overcoming  the  re- 
sistance of  the  lymph  nodes,  enter  the  blood. 

Symptoms. — The  different  forms  of  septicsemia  differ  so  widely  in  their  clin- 
ical manifestations  that  it  will  be  best  first  to  consider  the  symptoms  in  general, 
and  then  to  present  some  of  the  more  important  types  of  the  disease. 

The  symptom  to  which  our  attention  is  first  called  in  septicsemia  is  fever.  In 
general,  it  shows  itself  at  first  as  a  moderately  high,  continuous  fever.  The 
morning  and  evening  temperatures,  as  a  rule,  vary  but  little.  Sometimes,  but 
not  always,  the  fever  is  ushered  in  by  a  chill  or  a  feeling  of  chilliness.  In  a  pure 
septicemia  repeated  chills  seldom  occur.  In  the  more  severe  types  of  the  disease, 
especially  when  due  to  a  mixed  infection  and  when  there  is  present  a  large 
amount  of  necrotic  and  purulent  material  in  the  wound,  the  body  temperature  is 
high.  In  other  cases  the  temperature  may  be  low  and  even  subnormal,  and 
this  is  always  an  unfavorable  sign,  especially  when  accompanied  by  a  rapid 
and  feeble  pulse.  When  convalescence  is  established  the  body  temperature 
gradually  sinks  to  normal. 

The  pulse  is  a  much  more  important  criterion  of  the  patient's  condition  than 
the  temperature.  At  first,  in  the  milder  forms,  the  heart's  action  is  not  especially 
accelerated,  but  as  the  disease  progresses  the  arterial  tension  is  lowered  and  the 
pulse  becomes  rapid  and  feeble.  In  the  most  virulent  forms  the  heart's  action 
quickly  loses  in  power,  and  many  circulatory  disturbances  make  their  appearance. 

The  nervous  system  is  very  soon  affected  by  the  toxins.  At  first  the  patient 
may  complain  of  headache  and  a  feeling  of  general  discomfort  or  pain  in  the 
wound,  but  this  soon  gives  way  to  apathy  and  lack  of  interest  in  his  condition 
and  his  surroundings.  This  state  may  alternate  with  restlessness,  but  grad- 
ually stupor  comes  on,  and  in  the  fatal  cases  coma  and  death  follow.  Delirium 
does  not  generally  occur. 

A  great  change  takes  place  in  the  patient's  general  condition.  There  is  pro- 
found prostration.  The  surface  of  the  body,  at  first  dry  and  hot,  later  is  bathed  in 
perspiration,  the  skin  feeling  cold  and  cadaveric.  The  patient  loses  weight  rap- 
idly. The  expression  is  listless,  the  face  being  drawn  and  colorless ;  the  eyes  are 
sunken,  and  the  ale  nasi  dilated.  The  tongue  at  first  is  thickly  coated,  and  later 
becomes  covered  with  dry,  hard  crusts. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE. 


427 


Almost  always  the  patients  suffer  from  severe  gastro-intestinal  symptoms. 
At  first,  there  is  loss  of  appetite  and  the  thirst  increases.  Nausea  and  vomiting 
are  frequently  observed,  and  diarrhoea  is  the  rule.  In  the  more  severe  cases 
there  may  be  active  vomiting  and  purging,  as  in  cholera. 


di^eaTe 

9 

10 

11 

13 

13 

14 

15 

16 

17 

EVACUATIONS 

8 

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5 

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.... 

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P.M. 

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p.„. 

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10T° 
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98° 

97° 

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Fig.   130. — Typical  Temperature  and  Pulse  Chart  of  Second  Week  of  Septicaemia.     Note  rapidity 
of  pulse  and  frequent  evacuations  of  bowels. 

The  skin  often  shows  a  yellowish  tinge,  and  a  variety  of  eruptions  may 
appear. 

The  urine  shows  albumin  and  casts. 

If  the  disease  responds  to  treatment,  a  general  improvement  of  the  sensorium 
is  first  noted;  the  pulse  becomes  a  little  stronger,  although  still  rapid;  the 
body  temperature  gradually  subsides,  often  showing  at  first  marked  morning 
remissions,  until  finally  the  evening  rise  disappears;  the  desire  for  food  grad- 
ually returns ;  the  heart  is  the  last  entirely  to  recover  its  normal  condition. 


428  AMERICAN  PRACTICE  OF  SURGERY. 

As  has  been  already  stated,  we  recognize  clinically  several  different  types  of 
septicemia. 

Type  I. 

The  patient  has  suffered  a  compound  fracture  of  one  of  the  long  bones.  A 
few  days  later  the  signs  of  infection  develop  in  the  wound.  Local  treatment 
does  not  dimin  sh  the  inflammation,  and  active  suppuration  takes  place.  This 
rapidly  spreads  and  the  lymph  channels  become  involved,  and  all  the  symptoms 
of  a  severe  general  septic  intoxication  develop.  There  is  no  attempt  at  healing 
in  the  wound.  The  body  temperature  has  become  continuously  high  and  the 
pulse  increasingly  rapid.  As  the  disease  progresses  the  patient  becomes 
apathetic.  Vomiting  occurs.  There  are  four  or  five  loose  diarrhoeal  movements 
of  the  bowels.  Examination  of  the  blood  may  demonstrate  the  presence  of 
pyogenic  bacteria.  Prompt  and  extensive  local  incisions  and  antiseptic  applica- 
tions may  check  the  further  advance  of  the  disease.  The  constitutional  symp- 
toms gradually  disappear,  convalescence  is  established,  and  the  wound  heals. 

Or  the  disease  may  be  much  longer  in  its  course  and  not  react  so  quickly  to 
treatment.     The  following  case  will  serve  as  an  example : 

A  young  and  healthy  adult  receives  a  gunshot  wound  of  the  shoulder.  He 
is  taken  to  the  hospital  and  the  wound  is  treated  antiseptically.  At  first  there 
are  symptoms  of  shock,  but  these  rapidly  pass  away  and  the  temperature  and 
pulse  are  normal.  An  examination  of  the  wound  shows  the  presence  of  dark 
fluid  blood  and  serum,  which  are  easily  expressed  from  the  cleanly  cut  opening 
of  the  bullet  wound.  Surrounding  this  opening  there  is  more  or  less  cedema- 
tous  swelling  of  the  parts.  Pressure  elicits  pain.  Second  day :  The  general  con- 
dition is  satisfactory.  The  body  temperature  is  100°  F. ;  pulse,  of  good  qual- 
ity and  about  100  to  the  minute.  Pain  only  on  muscular  motion.  Third  day: 
Patient  feels  ill,  is  very  thirsty,  and  has  no  appetite.  Evening  temperature  is 
103°;  pulse,  110.  Some  pain  in  shoulder,  increased  by  motion.  Fourth  day: 
The  dressings  are  changed ;  they  are  found  to  be  dry.  The  womid  is  covered 
with  a  dry,  hasmato-fibrinous  exudate;  no  pus;  no  symptoms  of  local  infection. 
Evening  temperature,  102.5°;  pulse,  105.  Tongue  coated  and  moist.  Fifth  day: 
Sleeps  poorly.  Great  pain  in  shoulder,  increasing  thirst.  Evening  temperature, 
103.6°;  pulse,  120  and  of  good  quality.  Sixth  day:  Morning  temperature,  102° ; 
pulse,  110.  The  pain  in  the  shoulder  has  increased.  The  tongue  is  dry  and 
coated.  The  patient  is  restless.  On  inspection  the  wound  shows  the  entrance 
point  closed  by  a  dry,  hard  crust.  The  surrounding  tissues,  however,  are  swollen 
for  some  distance  from  the  wound,  moderately  hypertemic,  and  very  painful  to 
pressure.  It  is  possible  to  express  some  pus  from  the  wound.  Immediately  the 
region  is  incised  and  the  entire  course  of  the  bullet  is  laid  open.  Considerable 
purulent  exudate  is  discovered,  and  one  or  two  small  abscesses  are  opened.  The 
tissues  are  discolored,  oedematous,  and  infiltrated.  Some  bone  destruction  is 
found.     The  purulent  exudate  is  seen  to  issue  from  fissures  in  the  surrounding 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE. 


429 


tissue.  Some  bone  splinters,  possiblj'  a  piece  of  clothing,  and  the  bullet  are 
removed.  The  wound  is  treated  antiseptically  and  drained.  Seventh  day: 
General  condition  somewhat  improved,  less  pain.  Evening  temperature,  102°; 
pulse,  110  and  of  good  quality.  During  the  next  five  days  the  purulent  exudate 
in  the  wound  becomes  progressively  less.  Granulations  begin  to  appear.  The 
morning  and  evening  temperatures  are  lower.  On  the  following  day,  however, 
the  patient  complains  again  of  severe  pain  in  the  shoulder.    Evening  tempera- 


oiSeAM 

10 

11 

r-i 

13 

14 

15 

10 

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y 

Fig.  131. -^Temperature  and  Pulse  Curves  of  a  Case  of  PyosepticEemia.  Formation  of  multiple 
pus-containing  cavities  wliich  spread  rapidly.  In  some  places  extensive  areas  of  necrotic,  foul-smelling 
tissue  were  found ;   also  gas  abscesses.     Multiple  and  repeated  incisions. 

ture  jumps  up  to  103°;  pulse,  120.  Considerable  prostration.  Patient  listless. 
Exploration  of  the  wound  does  not  demonstrate  any  new  pus  foci ;  simply  dis- 
colored, oedematous,  infiltrated  tissues.  Despite  wide  incisions,  the  evening 
temperature  reaches  103.5°;  pulse,  130  and  irregular.  Energetic  surgical  treat- 
ment fails  to  produce  any  change  for  the  better  in  the  patient's  condition.  The 
average  evening  temperature  during  the  next  week  is  about  102.5°,  with  morn- 
ing remissions  to  99.5°  or  100°;   the  pulse  between  90  and  120.    At  the  end  of 


430  AMERICAN  PRACTICE  OF  SURGERY. 

the  second  week  staphylococci  are  found  in  the  blood  and  urine.  At  about  the 
same  time  a  retained  collection  of  pus  is  found  in  the  wound.  There  is  no  odor  of 
decomposition  or  putrefaction.  Occasionally  the  body  temperature  shoots  up  to 
103°  or  even  104°,  the  pulse  to  120.  At  the  end  of  three  weeks  the  temperature 
remains  the  same,  but  the  pulse,  on  the  slightest  exertion,  runs  up  to  150  and 
becomes  quite  irregular.  Small  necrotic  areas  are  found  burrowing  outward 
from  the  womid.  Multiple  incisions  are  made.  Still  the  teinperature  remains 
high,  now  being  almost  continuously  above  103°  and  reaching  as  high  as  104.5°. 
Pulse,  140  to  150,  and  of  very  poor  quality.  Patient  sleeping  most  of  the  time. 
Delirious  at  times.  Repeated  blood  cultures  show  the  presence  of  the  Staphy- 
lococcus pyogenes  in  the  blood.  All  of  this  time  the  wound  has  been  most 
energetically  treated,  and  the  most  advanced  therapeutic  measures  have  been 
used  to  sustain  the  strength  of  the  patient  and  overcome  the  poisons  of  the 
disease.  Finally,  at  the  end  of  the  fourth  or  fifth  week,  the  wound  begins  to  look 
healthier.  The  temperature  does  not  rise  so  high  in  the  evening  and  the  pulse 
is  more  regular.  Gradually  the  constitutional  symptoms  abate,  the  local  con- 
ditions improve,  and  at  the  end  of  the  eighth  or  ninth  week  the  temperature 
remains  normal.  The  pulse  is  still  rapid,  110  to  120,  but  it  gradually  returns 
to  normal. 

Into  this  class  of  septicaemia  fall  those  cases  in  which  there  is  no  mixed  infec- 
tion and  where  the  symptoms  are  due  more  to  the  toxins  and  ferments  of  the 
bacteria  themselves  than  to  the  added  resorption  of  the  products  of  decom- 
position. Of  course  necrosis  always  occurs  in  such  cases,  but  it  is  not  by  any 
means  a  prominent  symptom.  In  this  class  of  cases  the  onset  often  is  gradual, 
but  it  may  be  sudden  and  severe.  Many  examples  of  these  cases  are  seen  in  in- 
fections of  the  loiee-joint.  The  area  of  local  tissue-necrosis  is  not  great,  but  the 
bacteria  and  their  toxins  are  rapidly  reabsorbed  and  give  rise  to  grave  constitu- 
tional symptoms.  Another  example  is  seen  in  the  so-called  post-mortem  infec- 
tions. Here  there  is  seldom  much  tissue-necrosis,  and  often  the  local  infection  is 
so  insignificant  that  it  entirely  escapes  the  notice  of  the  surgeon.  The  develop- 
ment of  the  general  infection,  or  bacteritemia,  is  rapid  and  severe,  and  the  disease 
often  proves  fatal  in  a  remarkably  short  time. 

The  prognosis  in  this  type  of  cases  depends  upon  the  early  recognition  of  the 
primary  focus  of  infection  and  upon  the  thoroughness  and  promptness  with  which 
the  antiseptic  treatment  is  carried  out.  Even  after  the  bacteria  have  reached  the 
general  circulation,  if  the  local  focus  of  infection  can  be  entirely  eradicated,  the 
chances  are  that  the  bacterisemia  will  rapidly  disappear 

Type  II. 

This  type  comprises  those  cases  which  are  known  as  cryptogenetic  septiccpmia. 
In  the  one  set  of  cases  there  is  a  history  of  injury.  A  simple  fracture,  a  con- 
tused wound  or  hematoma  without  external  wound,  or  a  crushing  injury  of  a 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  431 

bone  are  among  the  most  common  examples.  Following  these  injuries  are  the 
usual  signs  of  traumatic  inflammation.  This  inflammation  does  not  undergo 
resolution,  but  very  soon  gives  rise  to  a  decided  febrile  movement,  which  may 
be  initiated  by  a  chill  or  sensation  of  chilliness.  All  the  local  signs  of  a  suppura- 
tive inflammation  appear.  The  constitutional  symptoms  increase  and  a  septi- 
ca3mia  develops. 

In  the  other  set  of  cases  there  is  no  history  of  any  wound  or  injury,  and  with- 
out known  cause  the  patients  gradually  or  suddenly  develop  the  symptoms  of  a 
general  septic  infection.  The  course  may  be  acute,  subacute,  or  chronic,  but  as  a 
rule  the  s5aiiptoms  of  multiple  pus  foci  develop,  and  we  have  a  transition  into 
pyaemia. 

The  etiology  of  these  conditions  has  already  been  discussed  in  the  article  on 
Inflammation. 

Type  III. 

To  this  type  belong  the  cases  of  septicsemia  due  to  a  mixed  infection. 

Under  this  division  of  septicaemia  we  have  to  deal  with  a  condition  whose 
manifestations  vary  according  to  the  local  pathological  conditions.  It  is  brought 
about  by  a  number  of  different  micro-organisms  working  together,  a  poly-infec- 
tion, causing  extensive  local  necrosis  and  decomposition,  as  well  as  a  general 
infection  of  the  system.  Often  streptococci,  the  Bacillus  coli  communis,  the 
Proteus  vulgaris,  and  the  Bacillus  pyocyaneus  are  associated  together  in  such  a 
process.  The  symptoms  naturally  vary,  but  an  example,  taken  from  actual  ex- 
perience, may  best  be  used  to  illustrate  the  condition. 

The  patient  has  received  some  injury  to  the  spine,  and  as  a  result  a  chronic 
myelitis  has  been  set  up.  Despite  careful  and  constant  attention,  the  patient's 
condition  grows  worse  and  a  number  of  bed-sores  develop.  One  or  more  of  them 
grow  larger  and  become  infected.  The  skin  is  undermined  and  a  collection  of 
foul-smelling  pus  is  evacuated.  The  patient  has  developed  a  high  fever,  with  all 
the  symptoms  of  a  general  septic  intoxication.  A  large  fluctuating  abscess  forms 
on  the  thigh  and  spreads  rapidly  to  the  knee.  When  it  is  opened,  a  large  quantity 
of  foul,  gas-containing  pus  escapes.  Large  masses  of  necrotic  tissue  are  seen 
everywhere.  There  is  no  appearance  of  healthy  granulation  tissue.  An  exam- 
ination of  the  urine  shows  Bacterium  coli.  The  blood  shows  a  pure  culture  of 
Proteus  vulgaris.  The  evacuated  pus  contains  cultures  of  Bacterium  coli,  Pro- 
teus vulgaris,  and  streptococci.  These  agents  working  together  rapidly  over- 
come the  patient,  who  dies  in  coma. 

The  symptoms,  then,  are  those  of  an  extensive  local  necrosis  combined  with 
the  symptoms  of  a  general  septic  infection.  The  body  temperature  is  generally 
high,  but  very  irregular  and  remittent  in  type.  The  pulse  rate  is  high  and  the 
nervous  system  is  markedly  involved.  The  blood  changes  are  not  constant,  and 
it  is  not  always  possible  to  demonstrate  bacteria  in  the  blood.    As  a  rule,  meta- 


432  A^IERICAN  PRACTICE  OF  SIT^GERY. 

static  foci  do  not  develop.  Tlie  s3'mptoms  are  due  more  to  absorption  from  the 
local  necrotic  focus  than  to  the  bacterisemia. 

The  prognosis  is  almost  always  bad  in  these  cases.  Prophylactic  treatment 
is  most  important,  while  extensive  incisions  and  strenuous  antiseptic  applica- 
tions are  called  for  when  the  process  is  established. 

During  the  course  of  any  of  the  various  types  of  septicemia  which  have  just 
been  described,  the  symptoms  of  metastatic  pus  foci  may  develop  and  the  symp- 
toms of  pygemia  will  then  be  added  to  those  of  the  existing  septictemia. 

Pathological  Anatomy. — In  the  most  acute  and  severe  forms  of  septicsemia 
the  process  is  so  rapid  that  few  gross  pathological  lesions  maj^  be  demonstrated. 
In  such  cases  there  are  no  special  changes  in  the  original  wound.  In  the  less 
severely  acute  cases,  due  to  the  action  of  pyogenic  micro-parasites,  the  edges  of 
the  original  wound  first  show  inflammator}^  redness  and  become  puffed  up  and 
swollen.  If  the  wound  is  an  open  one  the  granulations  look  unhealthy  and  the 
wounded  sm-faces  are  covered  with  a  fibrmous  exudate.  In  these  cases  a  foul, 
necrotic  odor  is  usually  absent.  There  are  manj-  exceptions  to  this  rule,  and 
cases  are  seen  in  which,  within  a  few  hours  of  the  accident,  the  wound  secretion 
is  most  foul.  These  cases  are  the  most  virulent  we  have  to  deal  with,  and 
generally  terminate  fatally  within  a  few  days.  The  common  pus  of  a  suppurat- 
ing wound  is  odorless,  and  the  presence  of  a  necrotic  odor  generally  signifies  the 
presence  of  bacteria  other  than  the  staphylococcus  and  streptococcus.  The  local 
infection  may  be  represented  by  a  fairly  large  and  extending  area  of  putrefying 
or  gangrenous  tissue,  or  by  an  extensive  septic  phlegmon.  The  primary  focus 
may  be  a  carbuncle,  an  otitis  media,  an  osteomyelitis,  a  pneimionia,  or  anj^  sup- 
purative process.  The  l}'mphatics  are  frequently  involved,  and  varj^ing  degrees 
of  IjTnphangitis  and  IjTnphadenitis  are  observed.  In  the  more  severe  cases  there 
is  a  rapid  development  of  a  severe  angemia .  The  bacteria  and  their  toxins  are 
present  in  the  blood.  The  red  blood  cells  are  diminished  in  nmnber  and  show 
degenerative  changes.  Leucoq/tosis  is  variable.  In  the  severe  and  rapidlj^  fatal 
cases  there  is  little  if  any  leucocytosis.  In  the  chronic  cases  it  is  moderate,  but 
in  the  subacute  cases  the  leucocytosis  is  sometimes  marked.  The  phenomena 
of  thrombosis  and  embolism  are  not  present. 

After  death  decomposition  sets  in  rapidly.  The  blood  is  dark,  does  not  coag- 
ulate well,  and  cjuickly  decomposes.  The  most  constant  changes  are  seen  in  the 
gastro-intestinal  tract.  Small  ecchymotic  spots  may  be  seen,  especially  in  the 
mucous  membrane  of  the  stomach,  duodenum,  and  rectimi.  There  is  a  marked 
gastro-intestinal  inflammation,  varying  in  degree  with  the  severitj^  of  the  toxin- 
Eemia.  The  solitary  follicles  and  Pej^er's  patches  are  swollen,  and  they  some- 
times break  do^Mi  and  form  ulcers.  If  the  intestinal  changes  are  severe  the  serous 
covering  of  the  intestines  may  share  in  the  process  and  give  rise  to  a  cloudy  or 
sero-sanguineous  exudate,  which  collects  in  the  peritoneal  cavitJ^  Tlie  patholog- 
ical findings  in  the  heart  and  limgs  are  variable.    There  may  be  small  effusions 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  433 

in  the  pericardial  and  pleural  cavities.  In  such  cases  the  effusion  is  apt  to  be 
cloudy.  Small  ecchymotic  spots  may  be  noted  on  the  pericardium,  endocardium, 
and  pleura.  QEdema  of  the  lungs  and  hypostatic  pneumonia  frequentlj^  precede 
death.  The  spleen  is  almost  constantly  enlarged.  Few  changes  are  noted  in  the 
liver,  aside  from  the  so-called  cloudy  swelling.  According  to  Hildebrand,  there 
occur  on  the  surface  of  the  kidney  small  areas  of  hypera^mia,  which  he  attributes 
to  the  heaping  up  of  micro-parasites  in  the  afferent  vessels  and  within  the  capil- 
laries of  the  glomeruli.  There  are  present  cloudy  swelling  of  the  kidney  and  a  ca- 
tarrhal inflammation  of  the  urinary  tract.   The  nervous  system  shov.'s  few  changes. 

PY.^MIA. 

P}^a?mia  is  a  general  infective  disease  of  the  body,  characterized  by  a  constitu- 
tional intoxication  in  which  the  signs  and  symptoms  of  metastases  break  in  upon 
the  general  symptoms.  It  is  not  possible  to  differentiate  etiologically  between 
septicEemia  and  pytemia.  As  a  result  of  the  most  extensive  experiments  by  many 
investigators,  it  has  been  discovered  that  the  same  micro-organisms  ma}'  give 
rise  to  both  conditions;  and,  further,  that  at  one  stage  of  the  disease  a  patient 
may  present  all  of  the  classical  symptoms  of  septictemia,  and  then  suddenly, 
without  any  added  etiological  factor,  the  clinical  signs  and  symptoms  of  a 
metastatic  focus  develop  and  a  transition  to  pycemia  takes  place. 

The  presence  of  the  pus-producing  microbes  is  essential  to  the  development 
of  pya?mia.  The  old  theory,  as  advanced  by  Piorry,  that  the  disease  is  always 
produced  by  the  entrance  of  pus  into  the  blood,  has  been  exploded.  It  is  true 
that  when  infected  pus  escapes  into  the  general  circulation  pyaemia  generally 
results,  but  in  the  majority  of  cases  it  is  not  due  to  such  a  cause.  A  primary 
focus  of  suppuration  is  the  rule  in  pyaemia,  but,  just  as  is  the  case  in  septicajmia, 
this  primary  focus  is  not  always  demonstrable.  From  this  primary  focus  the 
pyogenic  microbes  gain  access  to  the  circulation,  and  first  bring  about  a  general 
septicaemia.  The  microbes  carried  by  the  circulation  may  lodge  in  the  paren- 
chymatous organs  and  there  bring  about  a  secondary  inflammatory  process ;  sup- 
puration then  occurs,  and  a  metastatic  abscess  develops.  Or  the  condition  may 
be  brought  about  in  a  different  way;  that  is,  through  the  medium  of  a  thrombus. 
If  the  primary  suppurative  process  is  in  the  immediate  neighborhood  of  a  large 
vein,  the  walls  of  the  vein  are  apt  to  become  involved.  An  inflammatory  proc- 
ess develops  in  tlie  perivascular  spaces,  and  a  round-celled  infiltration  of  the  ad- 
ventitia  and  media  occurs.  The  intima  becomes  swollen,  a  proliferation  of  endo- 
thelium occurs,  and  fibrin  is  deposited  on  it.  This  becomes  the  nucleus  of  a 
coagulum.  Finally,  the  vein  becomes  occluded  by  an  extension  of  this  coagulum, 
and  a  thrombophlebitis  is  established.  This  process  extends  for  a  variable  dis- 
tance along  the  vein.  From  this  thrombus  small  bits  may  l^e  broken  off,  and, 
entering  the  general  circulation  as  emboli,  find  lodgment  in  the  various  organs, 
plugging  the  smaller  vessels  and  in  this  waj^  producing  infarcts.     These  in 

VOL.  I.— ?8 


434  AMERICAN  PRACTICE  OF  SURGERY. 

turn  may  tiecome  infected  by  the  bacteria  in  tlie  circulating  blood,  thus  givmg 
rise  to  metastatic  pus  foci.  Again,  in  the  primary  focus  the  microbes  may  invade 
the  thrombus  and  bring  about  purulent  softening  of  the  mass.  Portions  of  the 
thrombus  break  down  and  small  particles,  emboli,  laden  with  bacteria,  mix 
with  the  blood  stream  and  pass  through  the  heart  into  the  lungs.  The  heart  it- 
self does  not  always  escape,  and  a  suppurative  pericarditis  or  ulcerative  endo- 
carditis may  be  set  up.  The  heart  muscle  itself  is  seldom  invaded.  In  this  way 
metastatic  abscesses  may  be  set  up  in  almost  every  part  of  the  body.  In  the  lung 
a  metastatic  abscess  generally  is  preceded  by  the  formation  of  an  infarct,  due  to 
the  plugging  of  a  terminal  artery.  If  the  artery— in  some  other  .part  of  the 
body,  for  example — is  not  a  terminal  artery,  the  infected  embolus  gives  rise  to  an 
endarteritis  and  a  localized  abscess. 

Many  experiments  have  been  tried  to  ascertain  the  probability  of  pus,  when 
injected  into  the  general  circulation,  giving  rise  to  metastatic  abscesses,  and  as  a 
result  of  these  experiments  it  has  been  discovered  that  only  under  certain  con- 
ditions do  metastatic  abscesses  develop.  Only  when  large  quantities  of  unfil- 
tered  necrotic  stringy  pus— i.e.,  masses  which  acted  virtually  as  emboli— were 
repeatedly  injected  did  the  metastatic  foci  develop.  It  can  easily  be  understood 
that  such  conditions  as  these  seldom  occur  in  pyemia  in  man.  It  seems  much 
more  probable  that  the  bacteria  circulating  in  the  blood  may  become  agglutin- 
ated into  clumps,  a  number  of  these  clumps  coalescing  and  forming  a  plug,  which 
stops  up  the  small  capillaries,  and  thus  gives  rise  to  a  metastatic  focus.  This 
would  explain  many  of  the  metastases  which  are  found  in  the  kidney,  liver, 
muscles,  etc. 

There  are  certain  conditions  which  predispose  to  the  development  of  pyaemia. 
The  disease  seems  to  be  more  prevalent  in  overcrowded  hospital  wards,  and  in 
cities  which  contain  many  wounded  soldiers,  and,  in  general,  in  unsanitary  lo- 
calities. The  anatomical  structure  of  certain  tissues  predisposes  to  the  disease, 
and  suppurative  inflammation  of  these  tissues  has  long  been  looked  upon  as 
liable  to  develop  into  pyaemia.  This  is  especially  true  of  severe  woimds  of  the 
bones  of  the  skull  and  extremities,  of  wounds  of  the  joints  and  of  tendon  sheaths, 
and  of  traumatic  amputation  wounds  of  the  arms  and  legs;  it  is  also  true  of 
wounds  which  involve  the  large  veins. 

Sym-ptoms  and  Diagnosis. — As  has  been  already  stated,  pyaemia  may  develop 
at  any  time  in  the  course  of  a  septicaemia,  but  in  such  cases  the  number  of  meta- 
static foci  is  generally  limited  and  the  appearance  of  the  symptoms  of  new  pus 
foci  is  simply  incidental  and  does  not  in  general  alter  the  s3Tiiptoms  of  the  exist- 
ing septicaemia.  It  is  proposed  here  to  describe  a  condition  which  is  character- 
ized by  a  somewhat  different  train  of  symptoms,  presenting  a  distinctly  different 
clinical  picture. 

As  a  rule,  pyaemia  develops  durmg  the  period  of  suppuration  in  the  wound. 
It  may,  however,  develop  before  the  local  suppuration  has  taken  place,  owing  to 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE. 


435 


a  direct  infection  of  the  blood,  or  in  the  course  of  a  chronic  inflammation.  The 
latter,  however,  is  exceptional.  There  may  be  certain  premonitory  symptoms 
in  the  woimd,  such  as  its  general  appearance,  a  change  in  the  character  of  its 
secretion,  or  the  development  of  an  extensive  thrombo-phlebitis.  The  general 
system  shows  only  a  slight  degree  of  intoxication  at  first,  with  some  loss  of  appe- 
tite, general  malaise,  and  a  moderate  fever.  The  disease  itself  first  makes  itself 
manifest  by  the  occurrence  of  a  severe  chill.    This  is  the  rule,  but  there  are 


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Fig.  132. — Tj-pical  Temperature  Chart  of  a  Case  of  Pytpmia.  Primary  focus  in  pelvis;  meta- 
static foci  in  lung.  Stapkylococcus  pyogenes  demonstrated  in  the  blood.  The  case  was  accompanied 
by  marked  gastro-intestinal  sj'mptoms. 

many  exceptions  to  it.  The  most  characteristic  symptom  is  the  irregular  course 
of  the  temperature,  which  rapidly  changes  from  the  highest  point  to  the  lowest 
point  in  a  few  hom-s.  The  relation  of  the  chills  to  the  course  of  the  temperature 
is  not  always  constant.  Sometimes  the  chill  is  entirely  absent,  but  even  in  these 
cases  the  temperature  still  shows  the  marked  excursions  which  are  so  charac- 
teristic.   As  a  rule,  the  initial  chill  is  accompanied  by  a  rapid  rise  in  tempera- 


436  AMERICAN  PRACTICE  OF  SURGERY. 

ture,  ]3ut  in  those  cases  in  Avhich  a  septic  temperature  already  exists  this  rise  is 
not  so  marlced.  The  chill  and  rise  in  temperature  maj^  be  repeated  at  irregular 
intervals  during  the  da}^  or  night,  or  may  recur  regularly  every  day  or  every 
other  day,  thus  simulating  malaria.  In  the  more  acute  cases  the  chill  is  repeated 
three  or  four  times  in  a  single  da3^  Following  the  initial  chill  the  temperature 
ma}'  gradually  drop  to  normal  and  so  remain  for  several  daj^s,  to  be  again  inter- 
rupted by  the  occurrence  of  a  chill. 

The  course  of  the  temperature  is  usually  very  irregular,  and  is  intermittent 
or  remittent  in  type.  No  two  cases  are  alike,  and  in  fact  the  daily  temperature 
in  the  same  case  varies  from  hour  to  hour.  Some  cases  will  show  for  a  few /lays 
a  regular  morning  remission,  but  on  the  following  day  there  will  be  a  sharp  morn- 
ing rise  to  104°  F.  or  higher;  or,  during  the  course  of  the  night  there  may  be  a 
chill  and  a  sudden  rise  of  temperature  to  105°  or  over,  followed  in  a  few  hours 
by  a  drop  to  a  subnormal  temperature.  These  wide  excursions  of  temperature 
are  especially  characteristic  of  pyfemia.  In  exceptional  cases  there  is  a  regularly 
remittent  type  of  fever,  which  is  only  disturbed  by  the  occurrence  of  chills.  That 
a  chill  alwa}'-s  means  the  establishment  of  a  new  metastatic  focus  has  not  laeen 
clearly  proven,  but  it  is  held  by  the  majority  of  writers  to  be  the  most  probalale 
explanation  of  the  phenomenon. 

The  pulse  at  first  is  strong  and  full,  and  usually  varies  with  the  temperature, 
dropping  even  to  normal.  Later  in  the  disease,  it  becomes  rapid  and  weak,  and 
does  not  show  as  great  excursions  as  the  temperature. 

The  general  condition  of  the  patient  varies  with  the  severity  and  the  stage 
of  the  disease.  The  marked  apathy  and  prostration  seen  in  septictemia  are  alj- 
sent.  The  patient  is  painfully  conscious  of  the  severity  of  his  disease,  and  shows 
anxiety  as  to  his  condition.  Gradually  he  becomes  weaker,  and  the  effect  of  the 
toxins  upon  the  brain  may  become  more  e^'ident.  Delirium  may  develop.  Nau- 
sea and  vomiting  sometimes  accompany  the  hyperpyrexia,  and  diarrhoea  often 
occurs  late  in  the  disease.  The  tongue  becomes  dry  and  swollen,  and  the  Isreath 
is  foul.  An  especially  characteristic  feature  of  the  disease  is  the  yellowish  dis- 
coloration of  the  skin,  which  may  be  due  either  to  a  destruction  of  the  "red  blood 
corpuscles  and  a  consequent  deposit  of  pigment  in  the  skin,  a  hemorrhagic  icterus, 
or  to  inflammatory  changes  in  the  liver  itself.  The  urine  shows  the  usual  changes 
due  to  an  infective  disease. 

Of  greatest  importance,  and  a  most  characteristic  feature  of  the  disease,  are 
the  clinical  symptoms  of  the  development  of  metastases  in  the  various  organs 
and  tissues  of  the  body.  In  the  acute  and  severe  cases  the  lungs  are  the  organs 
most  frequently  the  seat  of  these  metastatic  abscesses.  However,  these  foci 
may  remain  so  small  that  they  do  not  give  rise  to  prominent  symptoms,  and,  as 
is  especially  true  in  the  chronic  cases,  the  muscles,  joints,  and  subcutaneous  tis- 
sues often  show  metastatic  foci  before  the  lungs  appear  to  be  invoh-ed.  It  is 
probably  true  that  in  every  case  of  pytemia  infarcts  occur  in  one  or  more  of  the 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  437 

internal  organs.  These  may,  however,  remam  microscopically  small  and  not  give 
rise  to  symptoms.  In  the  severe  forms  the  number  of  infarcts  is  generally  large. 
In  the  chronic  forms  the  number  of  secondary  foci  is  generally  small. 

When  the  lung  becomes  the  seat  of  a  metastatic  process,  the  first  symptoms 
are  an  increase  in  the  frequency  of  respiration  and  some  dyspnoea.  If  the  focus 
is  situated  in  the  substance  of  the  lung  it  gives  rise  to  the  symptoms  of  a  lobular 
pneumonia,  which  rapidly  resolves  itself  into  an  abscess.  If  it  is  in  the  neighbor- 
hood of  a  bronchus,  it  may  rupture  into  it  and  empty  itself  through  the  mouth, 
or  it  may  rupture  into  the  pleural  cavity  and  give  rise  to  the  symptoms  and  se- 
quelte  of  a  purulent  pleuritis,  empyema,  or  pyopneumothorax.  More  frequently, 
the  metastasis  takes  place  as  an  infarct  immediately  beneath  the  pleura,  and  a 
subpleural  abscess  results.    The  prognosis  in  these  cases  is  bad. 

The  diagnosis  of  liver  metastases  is  much  more  difficult.  The  occurrence  of 
icterus  does  not  necessarily  point  to  an  involvement  of  the  liver.  If  the  abscesses, 
which  necessarily  are  small  at  first,  are  deeply  seated,  a  diagnosis  is  often  impos- 
sible. Only  when  the  abscesses  are  situated  near  the  anterior  surface  of  the  liver 
is  it  possible  to  diagnose  them  wdth  certainty.  Abscess  and  infarcts  of  the  spleen 
and  kidney  are  of  less  freciuent  occurrence,  and  a  metastatic  abscess  of  the  brain 
is  only  exceptionally  seen.  The  diagnosis  of  metastatic  foci  in  the  muscles, 
glands,  and  connective  tissue  is  much  easier.  But  even  here  the  onset  is  often 
insidious,  and  the  abscess  may  not  be  discovered  until  it  is  well  advanced. 
Generally,  however,  the  usual  symptoms  of  a  suppurative  inflammation  are 
apparent,  and  the  diagnosis  is  established.  Freciuently  the  joints  and  bones 
become  involved  and  give  rise  to  characteristic  symptoms. 

In  all  of  these  secondary  foci  pyogenic  microbes  are  found. 

The  course  of  the  disease  may  be  acute  or  chronic.  In  the  acute  cases  the 
initial  chill  occurs  early  in  the  disease  and  is  frecjuently  repeated.  The  body 
temperature  is  very  irregular,  showing  a  characteristic  curve,  dropping  at  times 
from  above  105°  to  below  96°  F.  The  patient  rapidly  loses  flesh  and  strength, 
and  the  skin  reflects  the  profound  changes  in  the  blood.  Grawitz  reports  a  case 
in  which  after  two  days  the  red  blood  cells  were  reduced  to  300,000  per  cubic 
millimetre.  The  pulse  becomes  rapid  and  feeble,  ranging  from  110  to  160  per 
minute.  The  tongue  is  dry.  The  symptoms  of  metastases  develop,  but  the 
abscesses  do  not  reach  any  considerable  size.  The  stools  become  frequent  and 
are  often  blood-stained.  Delirimii  develops  and  is  followed  by  coma,  and  death 
takes  place  from  heart  failure,  or  suddenly  from  pulmonary  embolism,  often 
with  a  subnormal  temperature. 

The  chronic  cases  may  last  for  weeks,  or  even  months.  This  may  best  be 
illustrated  by  an  actual  case  which  occurred  in  the  Methodist  Episcopal  Hos- 
pital in  Brooklyn.* 

Patient,  a  few  days  previously,  had  suffered  from  an  attack  of  follicular  ton- 

*  Spence:  Brooklyn  Med.  Jour.,  June,  1904. 


438  AMERICAN  PRACTICE   OF  SURGERY. 

sillitis.  ^^'^len  first  seen  she  complained  of  headache,  general  abdominal  pain, 
and  fever.  Temperature,  103.6°  F.  Abdomen  someAvhat  distended  and  tender. 
Leucocj'tes,  9,400.  Widal  test  negative.  Second  clay,  slight  epistaxis,  vomiting, 
and  chill_v  sensations.  Fourth  clay,  slie  had  a  distinct  chill  and  complained  of  ten- 
derness of  the  left  forearm.  Leucocytes,  9,000.  Diazo  reaction  positive.  Tem- 
perature irregular  and  ranging  from  97.4°  to  105.6°.  Ever_y  day  there  were  chills 
and  profuse,  clammy  perspiration.  General  condition  steadily  growing  worse. 
Slight  tenderness  on  forearm  continued,  and  on  the  seventeenth  day  indistinct 
fluctuation  was  elicited.  An  incision  was  made,  and  pus  was  found,  dissecting 
its  way  between  the  flexor  muscles.  The  pus  showed  a  pure  culture  of  Strep- 
tococcus pyogenes.  On  the  nineteenth  day  a  small  collection  of  pus  was  discov- 
ered above  the  right  scapula.  This  was  evacuated.  Both  wounds  did  well.  The 
chills  and  fever  continued,  however,  and  there  was  no  change  in  the  irregular  up- 
and-down  course  of  the  temperature. 

The  patient  became  greatl}'  emaciated,  but  her  mental  condition  remained 
fair,  and  her  appetite  for  the  most  of  the  time  was  excellent.  A  slight  sys- 
tolic murmur  was  heard  at  the  base  of  the  heart,  but  disappeared  after  a  few 
days. 

At  the  end  of  the  fourth  week  the  patient  complained  of  pain  in  the  right 
shoulder,  and  there  was  some  tenderness  on  motion  and  when  pressure  was  made 
over  the  joint.  The  temperature  still  continued  its  irregular  course.  During 
the  sixth  iceek  she  became  restless  and  delirious  at  night.  The  pain  in  the 
shoulder  continued  with  varying  severity,  and  at  the  end  of  the  eighth  iceek  the 
shoulder  region  became  slightly  swollen.  An  incision  was  made  into  the  joint 
and  pus  was  evacuated.  A  gradual  improvement  immediately  followed.  The 
temperature  became  lower,  l3ut  did  not  remain  normal  until  the  fifteenth  week  of 
the  disease. 

At  times  there  were  points  of  tenderness  over  the  upper  and  lower  extremi- 
ities  and  on  the  chest.  There  was  no  redness  and  A'ery  little  swelling  at  those 
places  where  pus  was  found. 

Albumin  and  casts  were  present  in  the  urine,  but  disappeared  with  the  other 
symptoms.  The  wound  healed  slowly  and  motion  of  the  joint  was  gradually 
obtained. 

This  is  a  very  fair  example  of  a  class  of  cases  which  we  occasionally  see — 
cases  that  run  a  chronic  course  with  acute  exacerbations  and  terminate  in  re- 
covery. 

The  prognosis  of  pyaemia  is  almost  always  bad.  In  the  acute  cases  all  forms 
of  treatment  seem  to  be  unavailing,  and  the  patient  dies  in  from  one  to  three 
weeks.  In  the  chronic  cases  the  prognosis  is  somewhat  better,  but  even  here 
there  are  few  instances  of  recovery,  and  then  only  after  a  long,  protracted  ill- 
ness. When  the  metastatic  abscesses  involve  the  viscera  the  disease  almost 
always  proves  fatal. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  439 

Septico-pycemia. — "\'on  Leube  has  described  a  special  form  of  septic  infec- 
tion under  this  title,  and  although,  from  a  bacteriological  standpoint,  it  is  caused 
by  the  same  micro-organisms  which  give  rise  to  septiciemia  and  pysmia,  still  it 
should  be  clinically  differentiated  from  them.  The  patient  generally,  without 
any  known  suppurative  focus,  gradually  or  suddenly  develops  a  general  septic 
infection,  which  is  characterized  by  an  irregular  fever,  a  disproportionately  high 
pulse  frequence,  great  emaciation,  marked  nervous  manifestations,  and  special 
symptoms  referable  to  the  various  organs  in  which  the  septic  poisons  become 
localized.  The  fever  often  resembles  that  of  a  fluctuating  typhoid,  but  may  be 
continuously  high.  Chills  are  frequent.  The  heart  is  early  affected,  and  in  cer- 
tain cases  an  inflammation  of  the  endocardium  is  the  first  symptom  of  the 
disease.  Von  Leube  believes  that  the  so-called  malignant  endocarditis  is  only 
one  of  the  manifestations  of  this  disease.  Inflammation  of  the  joints  and 
serous  membranes  is  a  prominent  feature  and  of  frequent  occurrence.  Symp- 
toms referable  to  the  nervous  sj'stem,  such  as  headache,  vertigo,  sleeplessness, 
delirium,  convulsions,  and  temporar}^  paralysis,  are  quite  constant.  Icterus  is 
only  occasionally  seen.  The  kidne}^  is  markedly  affected.  Changes  in  the  skin 
are  almost  constant.  Roseola,  erythema-like  urticaria,  purpuric  spots,  hemor- 
rhagic pemphigus,  blisters,  pustules,  herpes,  etc.,  develop.  Metastatic  pus  foci 
may  occur  anywhere.  The  disease  runs  an  acute  or  subacute  course,  and  almost 
without  exception  terminates  fatall}'. 

Pathological  Anatomy.— The  pathological  changes  which  are  found  in  individ- 
uals who  have  died  from  pj^semia  are  not  always  constant,  but  in  general  they  are 
characteristic  of  the  disease.  The  primary  focus  of  suppuration  may  be  entirel}^ 
healed,  but  usually  in  the  acute  cases  this  is  not  the  case,  and  we  find  e\'idences 
of  a  gangrenous  or  necrotic  wound  in  the  neighborhood  of  which  the  veins  are 
inflamed  and  thrombosed.  In  the  chronic  cases,  especially  those  of  cryptoge- 
netic  origin,  there  are  evidences  of  multiple  abscesses.  The  heart  seldom  escapes 
entirel}^  and  frequently  a  purulent  pericarditis,  an  ulcerative  endocarditis,  or 
chronic  changes  in  the  valves,  are  found. 

The  most  constant  changes  are  found  in  the  lungs.  They  are,  for  the  most 
part,  due  to  the  lodgment  of  emboli  in  the  cortex  of  the  lung,  most  frequently  in 
the  lower  lobes.  These  emboli  plug  the  terminal  arteries  and  produce  wedge- 
shaped  infarcts.  The  embolus  either  contains  pyogenic  micro-organisms  or 
becomes  secondarily  infected  and  a  thrombus  is  formed.  A  septic  endarteritis 
is  set  up,  which  in  turn  infects  the  infarct,  and  a  circumscribed  abscess  results, 
which  lies  directly  beneath  the  pleura  and  maj'  give  rise  to  a  pleuritis,  empyema, 
pyopneumothorax,  etc.  However,  such  is  not  generally  the  case,  the  abscess 
remaining  localized.  Other  inflammatory  foci  may  also  be  established  in  the 
lung  independently  of  emboli,  and  lobular  pneumonia  then  results. 

The  liver  is  frequently  the  seat  of  metastatic  abscesses.  They  ^'ary  in  size 
from  microscopic  accumulations  of  pus  cells  to  an  abscess  which  may  destroy  an 


440  AilERICAN  PRACTICE  OF  SURGERY. 

entire  lobe.  Usually  they  are  not  due  to  emboli,  but  to  an  accumulation  of 
micro-parasites  in  the  smallest  capillaries.  The  infection  may  spread  to  the  por- 
tal vein  and  cause  there  a  thrombophlebitis. 

The  kidney  is  occasionally  the  seat  of  metastatic  abscesses,  but  more  fre- 
quently there  will  be  found  a  catarrhal  inflammation  and  cloudy  swelling.  The 
spleen  is  usually  enlarged  and  soft.  Brain  abscesses  are  not  frequent,  but  may 
occur  together  with  a  purulent  meningitis.  In  the  jonits  may  be  found  all  forms 
of  suppuration,  but  generally  not  of  a  severe  type.  The  knee,  ankle,  and  shoul- 
der joints  are  the  ones  generally  affectetl.  The  skin  also  may  be  the  seat  of 
some  inflammatory  disturbance,  the  severity  of  which  varies  from  a  mere 
erythema,  which  disappears  in  a  few  days,  to  a  subcutaneous  abscess.  All  or 
any  of  the  other  tissues  and  organs  may  be  invaded. 

In  the  chronic  forms  of  the  disease  various  degenerative  changes  are  seen. 
There  may  be  amyloid  degeneration  of  the  liver,  spleen,  and  kidney,  fatty  de- 
generation of  the  heart,  and  chronic  changes  in  the  valves.  The  lung  shows  the 
scars  of  many  infarcts  and  abscesses.  There  is  sometimes  a  chronic  exudative 
pleuritis.  A  chronic  enteritis  is  also  apt  to  be  present,  and  various  atrophic 
changes  are  seen  in  the  kidney.    The  patient  is  greatly  reduced  in  weight. 

treat:\iext  of  septicemia  and  pyemia. 

The  treatment  of  all  the  various  forms  of  general  septic  infection  resolves 
itself  into  an  attack  upon  the  pathogenic  bacteria  which  give  rise  to  the  disease, 
in  order  to  destroy  them  and  limit  their  activity,  and  to  remove  from  the  sys- 
tem their  toxins  and  the  results  of  their  action.  There  is  no  other  surgical  con- 
dition in  which  a  careful  prophylaxis  plays  so  important  a  part  as  it  does  in 
this  disease. 

Aseptic  and  antiseptic  surgery  are  two  distinctly  different  things.  The  for- 
mer has  to  do  with  the  prevention  of  infection  by  excluding  all  bacteria  from  the 
wound.  The  latter  deals  more  with  the  prevention  of  the  growth  of  bacteria  in 
a  wound  by  the  use  of  certain  chemicals  which  kill  or  attenuate  the  micro-organ- 
isms. The  primary  prophylaxis  of  septicaemia  and  pytemia  is  included  under 
the  consideration  of  these  subjects,  and  has  to  do  with  the  preparation  of  the 
patient  and  the  surgeon  for  the  operation,  the  sterilization  of  the  instruments, 
dressings,  etc.,  and  the  treatment  of  wounds  in  general.  The  general  hygiene  of 
the  patient  and  the  sick-room,  the  prevention  of  infection  in  various  surgical 
diseases  and  conditions,  and  the  treatment  of  infected  wounds  will  be  discussed 
by  other  writers,  and  it  is  therefore  not  necessary  that  I  should  consider  these 
subjects  in  detail  in  the  present  article. 

Many  surgeons  seem  to  overlook  the  importance  of  preventing  secondary  in- 
fection or  a  mixed  infection  in  a  wound.  It  is  just  as  important,  for  the  preven- 
tion of  a  general  septictemia,  to  guard  against  a  secondary  infection  in  a  wound 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  441 

as  it  is  to  prevent  primary  infection  in  a  clean  wound.  If  the  presence  of  infec- 
tion in  a  wound  is  discovered  early  enough  and  prompt  measures  are  taken  prop- 
erly to  drain  the  wound  and  all  the  foci  of  suppuration,  the  chances  are  that  gen- 
eral sepsis  will  never  occur.  In  the  presence  of  a  surgical  injury  or  any  condition 
in  which  the  vitality  of  a  part  is  lowered,  the  most  stringent  aseptic  measures 
must  be  adopted  to  prevent  infection.  Infections  of  necrotic  or  gangrenous  areas 
are  especially  apt  to  spread  rapidly  and  cause  a  general  septictemia.  In  the 
treatment  of  compound  fractures,  extensive  lacerated  and  contused  wounds, 
and  burns,  asepsis  should  be  carefully  carried  out. 

In  the  treatment  of  saprtemia  the  removal  of  the  putrefying  material  and 
general  stimulation  are,  in  most  cases,  followed  by  recovery. 

When  septicaemia  has  developed,  an  immediate  inspection  of  the  wound  must 
be  made ;  indeed,  it  should  be  thoroughly  explored.  All  pus  foci  must  be  evac- 
uated and  liberal  incisions  made,  in  order  to  establish  a  free  drainage  of  the 
woimd.  The  woimd  should  not  be  packed  Avith  antiseptic  gauze,  as  is  so  often 
advocated,  for  this  retards  the  evacuation  of  the  wound  secretion.  Large 
drainage  tubes  should  be  used  and  the  wound  frequently  irrigated.  Wlierever 
possible,  continuous  irrigation  is  called  for.  When  pyaemia  has  developed,  the 
secondary  foci  must  be  sought  for,  and  when  abscesses  form  they  should  be 
opened,  if  possible,  and  treated  in  the  same  manner  as  the  primary  focus. 
Fochier  observed  that  when  active  suppuration  occurred  in  pyjemia  and  septi- 
caemia the  general  condition  usually  improved.  He  therefore  tried  experiment- 
ally the  production  of  artificial  supvuration  in  such  cases.  This  may  be  done 
by  injecting  subcutaneously  from  2  c.c.  to  5  c.c.  of  rectified  turpentine.  There 
is  thus  created  an  abscess  in  which  the  pus  is  sterile.  In  six  of  the  cases  in  which 
he  tried  this  experiment  the  results  were  favorable :  a  general  improvement  oc- 
curred, and  the  temperature  was  lowered.  Trials  made  by  other  surgeons  have 
not,  however,  met  with  much  success. 

There  are  a  number  of  surgical  conditions  which  specially  call  for  early  inter- 
ference. Suppurative  osteomj'elitis  should  be  treated  early  and  radically.  Cer- 
tain rapidly  spreading  infections  of  the  extremities  call  for  amputation  as  the 
only  means  of  saving  life. 

Klebs  first  suggested  the  ligature  and  removal  of  veins  which  contained  in- 
fected thrombi,  before  the  emboli  should  be  broken  off  and  set  up  metastatic 
foci.  This  procedure  is  especially  applicable  to  thrombophlebitis  of  the  sigmoid 
and  lateral  sinuses  and  jugular  vein,  arising  from  suppuration  in  the  middle  ear. 
The  first  step  in  the  operation  is  the  ligation  and  excision  of  a  portion  of  the 
jugular  vein.  Then  the  sinuses  may  be  exposed  and  the  infected  material  thor- 
oughly removed.  This  procedure,  as  a  prophylactic  measure,  has  met  with  suc- 
cess in  the  hands  of  some  surgeons,  but  it  will  limit  the  disease  only  when  it  is 
due  to  the  lodgment  of  infected  emboli.  The  same  principle  has  been  suggested 
and  tried  in  cases  of  thrombophlebitis  of  the  portal  vein. 


442  AMERICAN  PRACTICE  OF  SURGERY. 

In  the  cases  of  septicemia  arising  from  general  peritonitis,  the  first  indication 
is  to  clean  out,  as  far  as  possible,  the  pus  and  serum  accumulated  in  the  peritoneal 
cavity.  The  second  indication,  of  no  less  importance,  is  to  clean  out  the  intestinal 
tract  and  establish  active  peristalsis.  The  method  originated  by  the  writer  in 
such  cases  is  as  follows :  The  first  portion  of  small  intestine  which  presents  itself 
in  the  wound  is  taken  and  a  purse-string  suture  is  introduced.  This  suture 
should  pass  through  the  serous  and  muscular  layers  and  should  include  an  area 
the  size  of  a  ten-cent  piece.  An  incision  is  made  within  this  area  and  a  small- 
sized  glass  catheter  is  introduced  through  it  into  the  lumen,  being  retained  in 
place  by  tying  the  suture.  Gas  and  fecal  material  are  allowed  to  escape.  Then, 
througli  the  catheter,  the  intestine  is  thoroughly  irrigated,  as  far  as  is  possible, 
with  hot  saline  solution.  After  this  has  laeen  done,  three  ounces  of  magnesium 
sulphate  is  introduced  through  the  catheter  into  the  lower  part  of  the  intestine, 
and  the  end  of  the  catheter  closed.  During  the  first  twenty-four  hours  the 
intestine  is  irrigated  every  three  or  four  hours.  Magnesium  sulphate  is  injected 
daily  and  the  irrigations  are  continued  as  long  and  as  frequently  as  indicated. 
In  this  way  it  is  possible  to  establish  active  peristalsis  and  aid  very  materially 
in  the  elimination  of  the  toxic  materials  from  the  system. 

The  local  treatment  in  puerperal  septicocmia  is  a  broad  question  and  can  be 
only  briefly  alluded  to  here.  Where  the  infected  process  is  localized  in  the  uterus, 
the  usual  methods  of  treatment  are  curettage,  hot  intra-uterine  irrigations, 
vaginal  douches  with  antiseptic  solutions,  and  the  application  of  an  ice  bag. 
These  measures,  combined  with  the  constitutional  treatment  to  be  described 
below,  axe  generally  followed  by  a  cure.  When  the  process  is  not  confined 
within  the  uterus,  more  drastic  measures  have  been  advocated.  Tuffier*  says 
"that  in  a  given  case  of  septica?mia,  post-partum  or  post-abortum,  when  no 
cause  for  the  fever  can  be  found  either  in  the  external  genitals  or  in  other 
organs,  when  the  usual  methods  of  treatment  are  of  no  avail,  when  the  peri- 
toneum and  adnexa  are  intact,  and  the  uterus  is  large,  flabby,  and  is  discharging 
fetid  lochia,  and  if  the  patient's  general  condition  warrants  it,  total  extirpation 
of  the  uterus  should  be  done,  whether  there  be  placental  retention,  a  sloughing 
myoma,  or  the  so-called  metritis  dissecans."  Many  surgeons,  however,  do  not 
agree  with  this.  The  late  Dr.  Pryor  advocated  splitting  the  posterior  lip  of  the 
cervix,  thus  providing  for  a  more  thorough  drainage  of  the  uterus,  opening  the 
cul-de-sac  of  Douglass,  and  packing  it  with  iodoform  gauze.  He  held  that  the 
iodine  set  free  and  absorbed  by  the  tissues  acted  as  a  powerful  local  and  general 
antiseptic. 

The  same  principle  applies  in  all  cases.  Wherever  possible,  limit  the  local 
activity  of  the  micro-organisms. 

General  Treatment. — The  first  indication  in  the  general  treatment  of  the  pa- 
tient is  to  foster  and  stimulate  in  every  way  the  excretory  organs  of  the  body. 

*  American  GjTiKcologj',  January,  1903. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  443 

The  bowels  should  be  made  to  act  regularl}',  and  the  rectum  should  be  emptied 
by  daily  enemata,  if  necessary.  Diaphoresis  and  diuresis  should  be  stimulated. 
The  general  hygiene  and  nursing  of  the  patient  are  of  the  utmost  importance. 
The  patient's  body  must  be  frequently  bathed,  and  he  should  be  given  every 
opportunity  to  obtain  fresh  air  and  sunlight.  The  nourishment  of  the  patient 
is  important.  Small  quantities  of  food  given  at  frequent  intervals  will  be  best 
borne  by  the  stomach.  If  the  patient  refuses  food  or  cannot  retain  it,  rectal 
enemata  must  be  given.  The  rectum  should  be  gently  washed  out,  and  then  an 
enema  containing  peptonized  milk,  peptonized  eggs,  and  whiskey  (not  exceeding 
four  or  fi.ve  ounces  in  amount),  should  be  given  ever}^  four  hours. 

Drugs. — In  general,  drugs  given  to  affect  the  course  of  the  disease  are  not  of 
much  avail.  Some  physicians  believe  that  calx  sulphurata,  given  in  ten-grain 
doses  every  three  hours,  will  retard  pus  formation.  Alcohol  is  the  one  drug 
which  seems  to  have  a  beneficial  effect  in  septic  conditions.  The  patients  stand 
it  well,  and  it  should  be  given  in  small  doses  frequently  repeated.  Symptomat- 
ically,  a  number  of  drugs  are  called  for.  Heart  stimulants,  such  as  tincture  of 
digitalis,  caffeine,  and  strophanthus,  are  often  indicated,  as  well  as  drugs  to  de- 
crease the  gastro-intestinal  inflammation.    Nerve  sedatives  may  be  necessary. 

Decinormal  Salt  Solution. — The  use  of  this  solution  in  various  ways  is  unques- 
tionably of  benefit  to  the  patient.  Wernitz  recommends  its  use  in  the  form  of 
hot  rectal  irrigations,  to  be  given  through  a  high  rectal  tube.  The  solution  is 
allowed  to  flow  in  gently,  and  the  procedure  is  continued  until  the  patient 
shows  discomfort,  or  until  the  return  flow  is  clear,  showing  that  the  lower  gut 
is  entirely  clean.  This  is  repeated  frec^uently  during  the  twenty-four  hours. 
Wernitz  claims  that  it  is  followed  by  a  falling  of  the  temperature,  profuse  dia- 
phoresis, increased  diuresis,  less  thirst,  and  a  general  improvement  in  the 
patient's  condition.  Repeated  submammary  or  subcutaneous  injections  of 
decinormal  salt  solution  may  be  given.  It  is  rapidly  absorbed  and  acts  as  an 
effective  cardiac' stinmlant,  increasing  diaphoresis  and  diuresis,  and  often  having 
a  distinct  sedative  effect  upon  the  patient.  Intravenous  infusions  ma}'  also  be 
indicated,  and  may  be  frequently  repeated.  Such  infusions  are  almost  always 
followed  by  beneficial  results,  and  it  is  probable  that  they  aid  materially  in  the 
elimination  of  the  toxic  material  from  the  tissues  and  the  blood. 

Serum  Therapy. — There  are  two  distinct  types  of  sera  used  in  septictemia. 
The  one  acts  by  virtue  of  its  antitoxic  properties,  and  the  other  acts  as  a  bacteri- 
cide. Antidiphtheritic  serum  is  an  antitoxin,  and  has  no  effect  upon  the  micro- 
organisms. It  has  been  shown  that  the  diphtheria  germs  can  be  made  to  grow 
on  diphtheria  antitoxic  serum.  The  antistreptococcic  serum,  on  the  other  hand, 
acts  as  a  bactericide  and  has  little  antitoxic  action. 

It  has  been  definitely  established  that  diphtheria  antitoxin  is  of  distinct  value 
in  the  treatment  of  septica?mia  caused  by  the  micro-organisms  of  diphtheria.  It 
is  a  specific.    This  is  made  possible  by  the  fact  that  the  same  organism  is  always 


444  a:merican  practice  of  surgery. 

the  cause  of  the  tlisease.  When  we  study  the  streptococci,  on  the  other  hand, 
we  find  that  all  streptococci  are  not  the  same;  that  is,  there  seem  to  be  nu- 
merous varieties  of  streptococci  which  cannot  be  differentiated  from  one  an- 
other. These  chfferent  varieties  vary  also  in  respect  to  their  virulence,  so  that 
when  a  streptococcic  serum  is  produced  it  will  be  found  to  vary  in  proportion 
to  the  virulence  and  variety  of  the  streptococcus  used  in  the  immunization.*  It 
is  not  strange,  then,  that  the  results  of  the  use  of  this  serum  should  vary  greatly. 

The  use  of  antistreptococcus  serum  is  indicated  in  those  cases  in  which  we  have 
a  pure  infection  of  the  streptococcus.  When  there  is  a  mixed  infection,  it  acts 
only  upon  the  streptococcic  factor  of  the  disease.  In  1902  Packard  and  Wilsonf 
collected  117  cases  in  which  the  serum  had  been  used,  and  they  report  recov- 
ery or  marked  improvement  in  114  of  the  cases. 

Bumm,  quoted  by  Young,  J  concludes  that  the  employment  of  antistrepto- 
coccus serum,  when  a  general  peritonitis  of  puerperal  origin,  a  pyaemia,  a  para- 
metritic phlegmon,  etc.,  exist,  is  ineffectual  and  useless.  He  believes  it  is  of  use 
in,  the  early  stages  where  the  organism  has  not  extended  beyond  the  endome- 
trium, or  where  an  extensive  bacterisemia  does  not  exist. 

The  serum  should  be  injected  early.  The  dose  varies  from  10  c.c,  repeated 
twice  daily,  to  25  c.c.  or  more,  injected  every  second  or  third  day. 

Intravascular  Antisepsis. — Since  the  disease  is  essentially  a  blood  disease, 
surgeons  have  long  sought  for  some  antiseptic  solution  which  could  be  injected 
into  the  circulation  and  destroy  the  organisms  without  doing  injury  to  the  pa- 
tient. Creole  was  one  of  the  first  to  experiment  along  this  line.  He  did  not  at 
first  inject  substances  directly  into  the  circulation,  but  caused  a  local  hyper- 
semia  of  the  skin,  and  then,  using  a  fifteen-per-cent  ointment  of  colloidal  silver, 
rubbed  2  or  3  gm.  of  the  same  into  the  hyperremic  area.  This  is  absorbed  by  the 
blood  and  attacks  the  micro-organisms.  Later,  he  injected  from  2  to  10  c.c.  of 
a  two-per-cent  solution  of  collargol  intravenously.  He  claims  that  it  is  a  non- 
irritating,  strongly  bactericidal  agent,  and  that  by  its  employment  marked  im- 
provement and  often  recovery  follow  in  even  the  most  severe  forms  of  septic 
poisoning.  ,  Many  surgeons  have  tried  this  method,  and  are  divided  in  their 
opinions  as  to  its  efficacy. 

Maguire,  of  London,  experimented  by  injecting  a  solution  of  formaldehyde 
gas  directly  into  the  circulation.  His  conclusions  were  that  50  c.c.  of  a  1  in  2,000 
solution  of  formaldehyde — that  is,  a  1  in  800  solution  of  formalin — was  the  max- 
imum dose  that  could  be  safely  injected  in  man.  In  1903  a  number  of  cases  of 
advanced  septicaemia  were  treated  by  injecting  this  solution  intravenously. 
The  results  at  first  were  encouraging,  but,  owing  to  the  dangers  and  uncer- 
tainty of  the  method,  it  has  not  come  into  general  use. 

*  Travel:  Klinisch-therap.  Wochenschrift,  1902. 

t  Amer.  Jour,  of  the  Med.  Sciences,  December,  1902. 

J  Boston  Med.  and  Surg.  Journal,  Aug.,  1905,  p.  216. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  445 

In  chronic  cases  most  attention  must  be  gi^-en  to  tlie  nourishment  and  gen- 
eral stimulation  of  the  patient.  Good,  nourishing  food,  fresh  air,  and  hygi- 
enic surroundings  are  essential. 

ERYSIPELAS. 

Erysipelas  is  an  acute,  inflammatory  disease  of  the  skin  or  mucous  mem- 
brane, caused  by  infection  of  a  wound  of  the  skin  or  mucous  membrane  by  the 
streptococcus  of  Fehleisen.  It  is  characterized  by  a  peculiar,  non-suppurative 
inflammation  or  dermatitis,  which  begins  in  the  wound  and  rapidly  spreads  over 
the  skin  or  mucous  membrane,  and  which  usually  is  self-limiting  and  ends  in 
resolution.    It  is  accompanied  by  fever. 

Etiology. — It  is  generally  accepted  that  erysipelas  always  arises  from  an  in- 
fection of  a  ^Yound  with  streptococci.  The  so-called  idiopathic  cases,  most  fre- 
quently seen  on  the  face,  are  not  due  to  infection  from  within,  but  in  everj'  case 
there  must  be  some  break  in  the  continviity  of  the  epithelium  covering  the  skin 
or  mucous  membrane.  The  original  wound  may  be  simply  an  abrasion  or  slight 
pin  prick,  and  may  he  entirely  healed  before  the  symptoms  of  erysipelas  develop ; 
nevertheless,  a  wound  of  some  sort  must  have  existed.  In  surgical  practice  ery- 
sipelas is  most  frequently  seen  as  a  complication  of  infected  wounds  and  in 
debilitated,  alcoholic,  or  other  patients,  in  whom  the  resisting  powers  of  the 
individual  are  diminished. 

The  existence  of  a  specific  micro-organism  is  still  in  question.  The  opinion 
of  many  bacteriologists  is  that  it  is  always  caused  by  the  streptococcus  of  Fehl- 
eisen. However,  there  is  a  diversity  of  opinion  on  this  subject.  Welch*  states 
that  "  the  streptococcus  of  erysipelas  does  not  differ  in  morphological  or  cultural 
characters  from  the  Streptococcus  pyogenes.  The  same  pathogenic  effects  may 
be  produced  by  each  in  animals  and  man,  so  that  the  weight  of  evidence  is  in 
favor  of  the  identity  of  the  Streptococcus  erysipelatis  with  the  Streptococcus 
pyogenes."  Clinically,  the  two  manifest  themselves  in  distinctly  different  ways, 
and  give  rise  to  different  pathological  processes. 

In  erysipelatous  inflammation  the  streptococci  are  found  chiefly  in  the  lymph 
capillaries  and  lymph  spaces  of  the  skin  and  subcutaneous  fat.  Here  they  mul- 
tiply rapidly,  and  often  are  seen  completely  filling  the  lumen  of  lymphatic  ves- 
sels. They  are  generally  found  most  abundantly  in  the  peripheral  margins  of 
the  inflammation.  If  the  inflammation  penetrates  more  deepl}',  which  is  un- 
usual, the  micro-organisnrs  are  found  in  the  connective-tissue  spaces. 

The  occurrence  of  suppuration  in  the  course  of  erj'sipelas  is  considered  by 
many  to  be  due  to  a  mixed  infection.  If  we  accept  the  theory  that  the  Strepto- 
coccus erysipelatis  and  the  Streptococcus  pyogenes  are  identical,  then  the  sup- 
puration is  caused  by  mono-infection.  If  we  believe  that  the  Streptococcus 
erysipelatis  is  a  non-pyogenic  micro-organism,  then  the  ^  occurrence  of  a  phleg- 
monous inflammation  must  be  due  to  a  mixed  infection. 
*  Dennis:  "System  of  Surgery.'' 


446  AMERICAN  PRACTICE   OF  SURGERY. 

The  micro-organisms  seldom  gain  entrance  to  the  general  circulation,  and  the 
constitutional  symptoms  are  due  to  resorption  of  the  toxins  from  the  seat  of 
infection. 

Erysipelas  is  a  highly  infectious  disease,  and  may  be  carried  by  instruments, 
the  hands,  clothing,  dressings,  etc.,  from  one  patient  to  another.  One  attack 
does  not  protect  against  a  second  attack.  In  fact,  some  people  seem  to  have  an 
especial  predisposition  to  contract  the  disease,  but  subsequent  attacks  are  not 
usually  so  severe  as  the  primary  one. 

Symptoms. — The  period  of  incubation  varies.  Generally  it  is  short,  from 
fifteen  to  sixty  hours,  or  it  may  last  for  from  three  to  seven  days  (Butler).  Dur- 
ing this  stage  there  may  be  indefinite  prodromal  symptoms,  such  as  headache, 
anorexia,  or  general  malaise.  Usually  the  symptoms  are  ushered  in  by  a  severe 
chill,  which  may  be  repeated.  This  is  followed  by  a  rapid  rise  of  temperature 
(104°  or  105°  F.),  accompanied  by  anorexia,  vomiting,  and,  in  debilitated  pa- 
tients, marked  depression.  At  the  same  time,  or  within  a  few  hours,  the  vicinity 
of  the  wound  is  seen  to  be  swollen  and  red.  At  first,  there  is  nothing  charac- 
teristic about  this  redness  and  swelling.  Frequently,  at  first,  small  red  streaks 
may  be  seen  to  radiate  from  the  wound,  corresponding  to  the  position  of  the 
lymphatics.  This  is  best  seen  when  the  disease  attacks  the  extremities.  Later, 
these  stripes  disappear.  The  redness  rapidly  extends  and  involves  a  considera- 
ble area.  The  lymph  nodes  are  more  or  less  swollen.  There  are  subjective 
symptoms  of  itching,  burning,  heat,  and  pain  in  the  affected  area. 

Usually  the  erysipelatous  patch  is  sharply  circumscribed.  It  is  elevated, 
irregular  in  contour,  rose-colored  or  of  a  bright  reddish  color,  and  presents  a 
smooth,  glazed  appearance.  'Wlien  pressure  is  made  with  the  finger  on  the 
hyperEemic  area,  the  redness  disappears  for  a  moment  and  the  skin  shows  a  pecul- 
iar, yellowish  discoloration.  The  swollen  tissues  do  not  pit  on  pressure.  The 
affected  part  is  tender  and  feels  somewhat  like  leather.  In  antemic,  cachectic 
individuals  the  redness  is  not  so  marked.  The  amount  of  swelling  varies  with 
the  severity  of  the  infection  and  the  part  affected.  When  there  is  much  loose 
connective  tissue  the  swelling  is  more  marked.  Often  on  the  surface  of  the  skin 
vesicles  appear  in  large  numbers.  Several  of  these  may  run  together  and 
form  large  bullce.  These  vesicles  and  bulla?  contain  clear  or  slightly  cloudy 
serum,  and  may  contain  pus.  As  the  inflammation  advances  they  dry  up  and 
form  crusts,  or  they  may  open  and  leave  an  ulcerated  surface. 

The  inflammation  is  i^rogressive  and  shows  a  great  tendency  to  spread.  On 
the  face  it  usually  develops  on  or  near  the  nose,  and  spreads  laterally  along  the 
lower  border  of  the  orbit.  In  men  it  has  often  been  noticed  that  it  stops  where 
the  beard  begins  on  the  cheek.  It  may  pass  up  over  the  forehead  and  invade  the 
scalp.  In  the  more  severe  forms  the  eyelids  become  greatly  swollen  and  close  up 
the  eyes.  The  disease  is  most  active  at  the  periphery  of  the  inflamed  patch,  and, 
while  it  is  thus  spreading  at  the  periphery,  it  may  be  subsiding  in  the  central 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  447 

portion.  It  may  further  extend  and  involve  the  neck.  In  facial  erysipelas  there 
is  always  danger  of  the  infection  penetrating  deeply  and  causing  meningitis. 
It  may  spread  from  the  skin  and  involve  the  mucous  membrane  of  the  nose  and 
mouth,  and  cases  of  pulmonary  erysipelas  have  been  reported.  In  severe  cases 
the  face  and  head  may  become  enormously  swollen  and  distorted,  and  such 
cases  are  accompanied  by  grave  constitutional  symptoms. 

The  inflammation  may  not  be  confined  to  any  one  portion  of  the  body.  It 
may  start  on  the  arm  or  leg  and,  steadily  and  irregularly  advancing  at  the  pe- 
riphery, creep  up  over  the  shoulder  or  thigh  and  spread  over  the  body.  At  the 
same  time  at  the  original  site  the  inflammation  may  subside  and  entirely  disap- 
pear, or,  after  temporary  subsidence,  it  may  start  up  again.  Such  a  condition, 
called  erysipelas  migrans  or  avibulans,  may  cover  a  period  of  weeks.  The  con- 
stitutional symptoms  are  not  generally  marked. 

Only  exceptionally  the  erysipelatous  inflammation  is  associated  with  sup- 
puration. The  pyogenic  process  may  be  superficial  and  result  in  the  formation 
of  pustules,  or  the  infection  may  involve  the  deeper  structures  and  set  up  a 
phlegmonous  inflammation.  This  does  not  differ  in  its  essentials  from  the  phleg- 
monous inflammations  already  described.  The  infection  may  involve  any  of  the 
deeper  structures,  and  there  have  been  reported  cases,  not  only  of  periostitis 
and  osteomyelitis,  but  also  of  joint  involvement.  Occasionally,  small  areas  of 
necrosis  and  small  localized  abscesses  may  form  throughout  the  erysipelatous 
patch.  All  grades  of  inflammation  are  seen,  from  the  mildest  dermatitis  to  the 
most  severe  form  of  acute  purulent  oedema  or  gangrene  foudroyante  of  Maison- 
neuve. 

The  constitutional  symptoms  vary,  as  a  rule,  in  proportion  to  the  intensity 
of  the  local  disturbance.  This,  however,  is  not  constant.  Sometimes  large  areas 
of  skin  are  involved  without  marked  systemic  symptoms.  The  body  temperature, 
as  a  rule,  is  characteristic.  Following  the  initial  chill  there  is  a  sharp  rise.  The 
first  day  the  temperature  may  be  only  103°  F.  The  next  .morning  there  is  no 
remission,  but  the  temperatvu'e  is  higher,  reaching  104°.  This  absence  of 
morning  remissions  is  considered  by  some  to  be  pathognomonic.  The  temper- 
ature continues  high  for  six  or  seven  days,  and  generally  terminates  by  crisis. 
Often,  however,  the  drop  to  normal  is  more  gradual.  In  exceptional  cases,  for 
the  first  few  days  the  temperature  may  not  be  high,  even  though  the  typical 
local  symptoms  be  well  developed.  At  times  the  temperature  is  very  irregular. 
Following  the  initial  chill  it  may  reach  106°  or  more,  to  be  followed  the  next 
morning  by  a  drop  of  three  or  four  degrees.  Again,  it  may  follow  the  type  of  a 
severe  remittent  or  intermittent  fever,  or  an  irregularly  remittent  fever.  Such 
irregularities  of  temperature  are  not  necessarily  associated  with  suppuration. 
The  temperature  usually  subsides  before  the  local  symptoms  disappear. 

The  disease  is  almost  without  exception  ushered  in  by  a  chill.  It  is  generally 
severe  and  lasts  for  some  time.    Or  the  chill  may  be  less  severe  and  be  repeated. 


448 


AMERICAN  PRACTICE  OF  SURGERY. 


The  chills  may  be  repeated  on  the  following  day,  or  every  day.    They  do  not 
necessarily  indicate  the  involvement  of  fresh  tissue. 

The  pulse  is  increased  in  frequencj^  and  usually  A^aries  in  proportion  to  the 
height  of  the  temperature,  seldom  becoming  A^ery  rapid  except  in  the  scA'ere  cases. 
The  gastric  SA'mptoms  are  often  more  prominent  at  the  beginning  of  an  attack. 
The  patient's  tongue  is  thickly  coated.    Loss  of  appetite,  nausea,  and  repeated 


DISEASE 

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1 

Fig.    133. — Typical  Temperature  Curx'e  of  a  Mild  Case  of  Facial  Erysipelas. 

vomiting  are  the  rule.  Diarrhoea  is  not  a  constant  symptom.  Often  severe  sjanp- 
toms  referable  to  the  nervous  system  are  obserA'ed.  Headache,  restlessness,  deliri- 
um, and  coma  occur.    These  are  more  pronounced  in  the  cases  of  facial  erysipelas. 

In  the  most  severe  cases  all  the  constitutional  SA'iiiptoms  of  a  general  intoxi- 
cation appear.  High  ieyer,  dry,  crusted  tongue,  alternating  delirium  and  coma, 
involuntary  evacuation  of  the  bladder  and  rectum  precede  a  fatal  termination. 

In  erysipelas  of  the  phlegmonous  type,  chills  often  recur  and  the  temperature 
assumes  a  more  tA'phoid  t3-pe. 

When  the  disease  attacks  the  mucous  meml^rane  lining  the  air  passages, 
marked  swelling  of  the  tissues  takes  place  and  fatal  oedema  of  the  glottis  maj'  occur. 

Numerous  complications  may  arise  during  the  course  of  the  disease.  Among 
the  most  common  may  be  mentioned  meningitis,  peritonitis,  pleuritis,  otitis 
media,  nephritis,  and  pneumonia;  also  septicaemia  and  pytemia. 

Diagnosis. — In  a  well-deA^eloped  case  of  erysipelas  the  diagnosis  is  often  easy. 
The  initial  chill,  with  the  rapid  development  of  a  continuously  high  temperature, 
together  with  the  marked  swelling  and  characteristic  rose  color  of  the  sharply 
defined  er3'sipelatous  inflammation,  are  pathognomonic.  "Where  the  s}anptoms, 
however,  are  not  so  characteristic,  the  diagnosis  is  often  difficult.    Sometimes, 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  449 

when  the  disease  develops  in  tlie  presence  of  other  infections,  a  diagnosis  is  im- 
possible. Occasionally  we  see  case.s  of  chronic  dermatitis,  with  redness  and  thick- 
ening of  the  skin,  which  simulate  erysipelas.  In  such  cases  there  is  no  tendency, 
on  the  part  of  the  disease,  to  spread;  and,  besides,  the  course  is  not  acute,  the 
area  affected  is  less  sharply  defined,  and  there  is  no  fever.  There  are  certain 
forms  of  acute  dermatitis  which  are  not  so  easily  distinguished  from  erysipelas. 
Especially  is  this  true  of  the  dermatitis  due  to  the  irritation  of  antiseptic  solu- 
tions, such  as  dilute  carbolic  acid,  sublimate  solution,  etc.  The  dermatitis  in 
such  cases  is  often  most  severe  in  the  vicinity  of  the  wound,  and  at  first  may 
simulate  an  erysipelatous  inflammation,  especially  in  the  presence  of  a  septic 
temperature.  The  inflammation  does  not  spread  so  rapidly  and  is  not  so  sharply 
circumscribed.  The  characteristic  swelling  and  glased  appearance  are  absent. 
Erysipelas  may  be  confused  with  a  progressive  ^phlegmonous  inflammation,  but 
in  the  latter  the  inflammation  does  not  usually  affect  the  skin  and  does  not  pre- 
sent the  sharply  defined,  raised  edges  seen  in  erysipelas.  In  simple  lym-phangitis 
the  inflammation  generally  follows  the  course  of  the  larger  lymph  vessels,  there 
is  no  typical  inflammation  of  the  skin,  and  the  diagnosis  is  not  difficult. 

In  traumatic  erysipelas,  if  the  woimd  be  large,  the  erysipelatous  inflamma- 
tion usually  is  seen  to  start  from  one  portion  of  the  wound  and  send  out  fan-like 
projections  into  the  normal  skin.  It  has  been  likened  to  the  flame  from  a  gas  jet, 
which  it  resembles  in  contour.  The  dermatitis  does  not,  as  a  rule,  involve  the 
entire  wound  symmetrically,  although  this  may  take  place.  There  is  not  much 
change  in  the  appearance  of  the  wound  itself.  The  secretion  may  be  diminished 
and  a  general  improvement  may  be  noted.  Another  point  of  diagnostic  interest 
is  the  fact  that  the  dermatitis  does  not  necessarily  spread  in  the  direction  of  the 
flow  of  lymph  in  the  lymph  vessels.  The  lymphangitis  ma}^  advance  against  the 
stream,  and  the  vessels  often  become  entirely  plugged  with  micro-organisms, 
which  multiply  rapidly  b}^  division. 

There  is  no  constant  relation  between  the  subjective  symptoms  and  the  height 
of  the  body  temperature.  Patients  are  often  seen  with  a  well-developed  ery- 
sipelatous dermatitis  and  with  a  temperature  of  104°  or  105°  F.,  without  any 
marked  constitutional  disturbance.  Such  a  condition,  however,  is  seen  only  in 
otherwise  strong  and  healthy  persons. 

Erythema  may  simulate  an  erysipelatous  dermatitis,  but  the  inflamed  area  is  not 
continuous,  and  areas  of  healthy  tissue  appear  between  the  erythematous  patches. 
The  temperature,  course,  and  constitutional  symptoms  help  to  differentiate  the  two. 

In  former  years  erysipelas  was  frequently  seen  as  a  complication  of  hospital 
gangrene,  especially  the  diphtheritic  form,  also  as  a  complication  of  diphtheritic  in- 
flammations of  the  throat  and  other  mucous  membranes.  In  these  cases  the  in- 
flammation of  the  mucous  membrane  was  usually'  of  a  gangrenous  type,  and  it  is 
questionable  whether  the  original  infection  was  due  to  the  streptococcus  of  ery- 
sipelas or  whether  it  occurred  as  a  secondarj^  infection.    Such  involvements  of  the 


450  AMERICAN  PRACTICE  OF  SURGERY. 

mucous  membranes  are  alwaj's  attended  with  great  swelling  and  difl'use  red- 
ness, which  are  not  especially  characteristic  and  make  the  diagnosis  most  difficult. 

The  relation  of  erysipelas  to  pyaemia  is  still  a  much  disputed  question.  Py- 
aemia does  sometimes  occur  during  the  course  of  the  disease,  secondary  foci  be- 
coming established  in  the  lungs  and  other  tissues,  and  giving  rise  to  inflammation 
and  suppuration.  It  is  most  frequently  observed  in  the  phlegmonous  and  gan- 
grenous types  of  erysipelas,  also  in  the  cases  of  erysipelas  which  develop  in  large, 
freshly  made  wounds  which  easily  develop  thrombophlebitis.  A  thrombus  may 
become  secondarily  infected  by  the  erysipelas  micro-organisms  and  so  occasion 
pyaemia.  The  same  is  true  of  the  relation  between  erysipelas  and  septicaemia. 
A  fatal  septicaemia,  which  does  not  differ  from  the  forms  of  septicaemia  already 
described,  may  at  any  time  develop. 

Pathological  Anatomy. — In  the  milder  cases  the  erysipelatous  inflammation 
is  most  frequently  confined  to  the  skin,  but  may  invade  the  underlying  con- 
nective tissue.  The  blood-vessels  are  markedly  dilated  and  are  crowded  with 
cells.  There  is  a  varying  degree  of  serous  exudation.  The  superficial  layers  of 
the  epidermis  are  raised  in  places,  forming  vesicles.  The  cells  of  the  rete  Mal- 
pighi  are  at  first  swollen  and  enlarged,  and  become  vacuolated,  but  later  they 
shrink  and  are  partly  destroyed.  The  serous  exudate  invades  the  hair  folli- 
cles, and  as  a  result  the  hair  becomes  separated  from  its  papilla  and  drops  out. 
There  occurs  a  rapid  and  profuse,  small-celled  infiltration,  which  is  first  ob- 
served in  the  cutis  and  subcutaneous  cellular  tissue  (Volkmann).  This  round- 
celled  infiltration  is  especially  marked  around  the  lymph  vessels,  and  may 
remain  after  the  bacteria  disappear.  The  lymph  vessels  become  filled  with 
streptococci,  which  often  entirely  plug  the  vessels.  According  to  Tillmanns,* 
the  small-celled  infiltration  becomes  crowded  together  in  the  cutis  and  subcu- 
taneous tissues,  and  often  forms  small,  microscopical  abscesses.  He  believes 
that  this  takes  place  more  frequently  than  is  generally  recognized;  further, 
that  the  most  active  stage  is  found  in  the  outlying  regions  of  the  erysipelatous 
patch,  and  sometimes,  more  especially  in  the  cases  complicated  with  pyaemia, 
during  the  acme  of  the  disease  the  connective  tissue,  the  lymph-,  and  small 
blood-vessels  are  filled  with  streptococcic  vegetations.  The  cocci  often  extend 
as  a  fine  network  through  the  tissues. 

It  is  not  always  possible,  however,  to  demonstrate  the  presence  of  the  bac- 
teria.   They  have  frequently  been  found  in  the  circulating  blood. 

In  the  typical  cases  the  local  symptoms  subside  after  three  or  four  days. 
The  round-celled  infiltration  disappears  rapidl}^,  while  the  serous  exudate  is  re- 
moved more  slowly.  In  the  phlegmonous  type  of  the  disease  the  changes  arc 
naturally  more  extensive  and  are  accompanied  by  suppuration  and  loss  of  tissue. 

The  secondary  systemic  changes  are  not  characteristic,  and  resemble  those 
which  usually  accompany  all  acute  febrile  infectious  diseases.  Degenerative 
alterations  are  seen  in  the  blood  and  the  vessels. 

*"  Deutsche  Chirurijie, "  Lieferuns  5. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  451 

Desquamation  usually  takes  place. 

Prognosis. — As  a  rule,  the  prognosis  is  favorable,  but  it  varies  with  the  severity 
of  the  infection  and  the  general  condition  of  the  patient  who  is  attacked.  In 
general,  the  mild  cases  run  their  course  in  about  a  week  and  the  disease  then 
subsides.  The  greatest  danger  arises  from  the  complications,  such  as  menin- 
gitis, oedema  of  the  glottis,  pysemia,  etc.,  which  have  already  been  mentioned. 

Treatment. — When  we  consider  the  etiology  and  pathology  of  erysipelas,  we 
find  that  it  is  a  disease  due  to  the  activity  of  streptococci  which  do  not  differ 
morphologically  and  physiologically  from  the  ordinary  pus-producing  strepto- 
cocci, and  that  under  ordinary  conditions  they  give  rise  to  an  inflammatory 
process  which  is  usually  localized  and  tends  to  be  self-limiting;  further,  that 
when  the  disease  invades  the  general  system  the  symptoms  resemble  those  pro- 
duced by  other  streptococci.  Finally,  we  believe  that  the  constitutional  symp- 
toms are  due  to  the  resorption  of  the  toxins  and  other  poisonous  products  elabo- 
rated by  the  bacteria,  and  to  the  effects  produced  by  the  action  of  the  bacterial 
toxins  on  the  tissues.  In  other  words,  the  conditions  are  similar  to  those  which 
are  found  in  other  wound  infections,  and  therefore,  aside  from  the  local  indica- 
tions and  serum  therapy,  the  general  treatment  should  be  the  same  as  is  em- 
ployed in  the  other  forms  of  wound  infections. 

ProphylcLris  is  of  greatest  importance.  The  disease  is  highly  infectious,  and 
is  communicable  by  means  of  any  object  or  medium  which  will  convey  the  bac- 
teria to  a  wound.  On  this  account  the  patient  must  be  isolated,  and  nothing 
which  touches  or  is  in  the  vicinity  of  the  patient  should  escape  disinfection. 

General  Treatment. — Good  nursing,  pure  air,  and  careful  attention  to  hygienic 
surroundings  are  important.  The  bowels  should  be  regulated  and  the  diet  should 
consist  chiefly  of  milk,  broths,  and  eggs.  Stimulants  are  sometimes  called  for. 
Alcohol  may  be  given  in  the  form  of  whiskey  or  brandy.  Alcoholic  beverages, 
such  as  beer  and  champagne,  may  be  used  in  suitable  cases.  The  chloride  of 
iron,  in  doses  of  twenty  to  forty  drops  every  two  hours,  has  been  extensively 
used,  but  not  so  much  now  as  in  former  years.  As  a  general  rule,  the  use  of 
antipyretics  is  contraindicated.  Salinger  strongly  recommends  the  hypodermic 
injection  of  pilocarpine.  The  drug  is  administered  until  the  physiological  effects 
are  produced.     All  drug  treatment,  however,  is  unsatisfactory. 

Local  Treatment. — The  various  methods  of  local  treatment  are  all  based  upon 
the  general  principles  of  antisepsis,  with  the  idea  of  allaying  the  local  inflamma- 
tion and  checking  the  spread  of  the  disease.  Of  all  the  antiseptic  solutions  used, 
those  of  corrosive  sublimate,  1  in  1,000,  and  carbolic  acid  in  varying  strengths, 
have  met  with  the  greatest  favor.  Corrosive  sublimate  may  be  employed  in 
the  form  of  compresses  kept  moist  with  the  solution  and  applied  to  the  erysipela- 
tous area,  or  it  may  be  injected  hypodermatically  around  the  edge  of  the  area. 
Carbolic-acid  solutions  may  be  similarly  used.  Kraske  advocated  scarification  of 
the  skin  at  the  periphery  of  the  inflamed  area,  and  then  the  application  of  a  warm 


452 


AMERICAN  PRACTICE  OF  SURGERY. 


solution  of  corrosive  sublimate.  Some  writers  recommend  painting  the  diseased 
area  and  the  surrounding  skin  with  tincture  of  iodine.  Others  applj'  compresses 
kept  moist  with  alcohol,  sodimn  hyposulphite,  potassium-permanganate  solu- 
tion, etc.  Cebrian  advocates  painting  the  affected  area  twice  daily  with  a  ten- 
per-cent  solution  of  ichthyol  in  collodion.  In  the  experience  of  the  writer  the  use 
of  a  ten-  to  twenty-per-cent  ointment  of  ichthyol,  mixed  with  an  equal  quantity 
of  vaseline  or  lanolin,  has  been  found  of  advantage.  The  diseased  area  is  first 
carefullj'  cleaned  with  soap  and  warm  water,  and  then  the  ointment  is  applied. 

When  suppuration  occurs,  incision  and  evacuation  of  the  pus  are  called  for, 
and  the  wound  should  be  treated  as  set  forth  in  the  chapter  on  that  subject. 

Serum  Therapy. — Antistreptococcus  serum  has  been  employed  for  over  a 
decade  in  the  treatment  of  erysipelas,  but  such  are  the  vicissitudes  of  the  disease 
that  it  is  impossible  to  say  accurately  how  much  good  comes  of  its  use. 

In  1895  Marmorek  reported  a  series  of  306  cases  of  erysipelas,  in  165  of  which 
antistreptococcus  serimi  was  used.  Prior  to  this,  the  average  mortality  was  as- 
sumed to  be  about  5.12  per  cent.  The  dose  varied  from  10  to  20  c.c.  In  this 
series  of  cases  the  mortality  was  1.63  per  cent.    When  a  weaker  serum  was  used, 


DISEASE 

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Fig.  134. — Temperature  Curve  of  a  Case  of  Facial  Erysipelas,  Showing  the  Effect  of  Injections 
of  Antistreptococcus  Serum. 

the  per  cent  rose  to  4.82.    After  the  injections  the  symptoms  diminished  mark- 
edly within  a  few  hours,  and  a  general  improvement  was  noted. 

Ayer*  reports  a  series  of  fifteen  cases  treated  by  injections  of  antistrepto- 
coccus serum.  He  concludes,  from  a  careful  study  of  these  cases,  as  compared 
with  a  series  of  seventy-nine  typical  cases  in  which  the  serum  was  not  used,  that, 
if  the  treatment  is  begim  early  enough,  the  course  of  the  disease  is  considerably 
shortened,  its  extension  is  inhibited,  and  that  there  is  a  striking  beneficial  effect 
*  Medical  Record,  March  4th,  1905. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  453 

upon  the  general  condition  of  the  patient,  the  temperature,  pain,  and  discomfort 
incidental  to  the  disease  being  reduced ;  further,  that  its  use  is  attended  with 
no  danger,  even  in  large  doses,  and  that  it  rapidly  reduces  the  pathological 
leucocytosis  and  prevents  or  suppresses  febrile  albuminuria. 

The  efficacy  of  the  treatment  depends  upon  the  promptness  with  which  it  is 
applied.  As  a  rule,  it  is  best  to  use  small  doses  frecjuently  repeated.  If  the  case 
is  seen  on  the  first  or  second  day  of  the  disease,  10  c.c.  should  be  injected  and  re- 
peated every  four  hours  for  four  or  five  doses.  If  the  patient  is  seen  first  on  the 
third  or  fourth  day  of  the  disease,  larger  doses  should  be  given. 

From  all  sides  good  results  have  been  reported  from  the  use  of  the  remedy. 

The  curative  influence  of  erysipelas  on  various  diseases  has  been  the  subject 
of  much  investigation.  Certain  chronic  diseases,  especially  of  the  skin  and  joints, 
have  been  favorably  affected  by  an  attack  of  erysipelas.  Cases  of  carcinoma 
and  sarcoma  which  have  been  cured  in  this  way  have  been  reported. 

TETANUS. 

Tetanus  is  an  infectious  disease  due  to  a  specific  organism,  the  tetanus  bacil- 
lus, and  is  characterized  by  intense  spasms  and  painful  contractions  of  certain 
definite  muscle  groups.    It  may  be  either  acute  or  chronic  in  its  course. 

Two  varieties  have  been  described — traumatic  tetanus,  due  to  infection  of  a 
wound  with  the  tetanus  bacillus ;  and  cryptogenetic  tetanus,  in  which  the  character- 
istic symptoms  of  tetanus  develop  without  a  discoverable  local  focus  of  infection. 
The  term  idiopathic,  when  used  in  such  a  connection,  is  especially  objectionable, 
because  it  indicates  that  the  disease  may  be  due  to  an  unknown  cause,  whereas 
we  know  definitely  that  tetanus  is  always  caused  by  a  certain  specific  organism, 
and  never  occurs  imless  the  specific  micro-organism  gains  access  to  the  tissues. 

Etiology. — As  has  been  already  stated,  the  disease  is  due  to  infection  with  the 
tetanus  bacillus.  The  micro-organism  is  a  strict  anaerobe,  and  cannot  be  made  to 
grow  in  the  presence  of  oxygen.  It  was  first  obtained  in  pure  culture  by  Kitasato 
in  1889,  but  was  previously  described  by  Nicolaier  in  1884.  It  is  fomid  widely 
distributed  in  the  soil,  especially  in  barnyards  and  in  soil  which  has  been  repeat- 
edly fertilized  with  manure.  Certain  localities  seem  to  be  especially  favorable 
for  its  growth,  as  has  been  demonstrated  in  certain  districts  of  Long  Island,  N.  Y. 
It  has  been  frequently  found  in  the  intestinal  discharges  of  the  horse,  and  some- 
times of  man.  It  would  seem,  from  numerous  experiments  and  the  observation 
of  actual  cases  in  man,  that  the  disease  does  not  always  develop  when  the  micro- 
organism gains  entrance  to  a  wound.  It  probably  follows  the  same  laws  of 
development  that  have  been  observed  in  infectious  diseases  due  to  other  micro- 
organisms. Wounds  which  are  accompanied  by  extensive  laceration  and  de- 
struction of  tissue  present  favorable  media  for  the  development  and  growth  of 
the  germs.  Suppuration  due  to  a  mixed  infection  favors  rather  than  hinders  the 
activity  of  the  bacilli.    Many  cases  of  tetanus  developing  after  supposedly  aseptic 


454  AMERICAN  PRACTICE  OF  SURGERY. 

surgical  operations  have  been  reported.  In  such  cases  the  carrier  of  the  infection 
has  often  been  thought  to  be  the  catgut  or  other  suture  material  used. 

It  has  been  observed  that  certain  climatic  influences,  mixed  infection, 
anaerobic  conditions,  and  burns  favor  the  development  of  the  disease.  Gunshot 
wovmds  and  the  usual  Fourth-of-Juh^  casualties  generally  present  the  last  two 
conditions,  and  often  produce  a  mixed  infection  as  well.  The  bullet,  powder, 
■^'adding,  etc.,  are  projected  into  the  body  and  penetrate  deeply,  often  becoming 
so  buried  in  the  tissues  that  air  is  excluded.  Local  destruction  of  tissue  takes 
place  and  hsematomata  are  formed.  There  is  greater  danger  from  blank  car- 
tridges than  there  is  from  ball  cartridges.  Dr.  Connolly,  of  Newark,  recently 
examined  blank  cartridges,  such  as  are  used  to  celebrate  the  Fourth  of  July, 
and  found  that  they  contained  the  germs  of  tetanus.  Dr.  Park,  of  the  New 
York  Board  of  Health,  made  extensive  investigations  along  the  same  line,  and 
was  unable  to  find  the  bacilli  in  the  blank  cartridges,  and  he  concluded  that  the 
infection,  under  these  circumstances,  was  due  to  the  fact  that  fragments  of 
skin  more  or  less  covered  with  dirt  were  driven  into  the  wound.  Fourth-of-July 
accidents  are  the  most  prolific  cause  of  tetanus  in  the  United  States.  More  than 
half  the  deaths  due  to  tetanus  are  caused  in  this  way.  In  a  statistical  report  of 
415  deaths  from  Fourth-of-July  tetanus,  published  in  1903,  most  of  the  victims 
were  boys,  and  most  of  the  deaths  resulted  from  blank-cartridge  explosions, 
causing  wounds  of  the  hand.  Contrast  this  with  the  tables  of  the  "Surgical 
History  of  the  War  of  the  Rebellion,"  which  show  only  337  deaths  from  tetanus 
out  of  an  enormous  total  of  deaths  from  all  causes. 

Many  cases  of  tetanus  follow  injuries  received  from  rusty  nails. 

How  does  the  bacillus  cause  the  disease?  When  the  bacillus  is  grown  in 
bouillon  it  produces  an  intense  poison  or  toxin,  and  experiments  have  shown 
that  when  this  toxin  is  injected  into  susceptible  animals  it  produces  all  of  the 
symptoms  of  the  disease.  "\'aillard,  Vincent,  and  Rouget*  have  found  that,  as 
a  rule,  when  the  spores  of  the  tetanus  bacillus  are  introduced  into  the  tissues, 
they  are  destroyed  by  the  leucocytes,  but  when  some  of  the  tetanus  toxin  is  in- 
troduced at  the  same  time  the  spores  develop.  Schutze  has  shown  that  when  a 
sterile  putrefactive  solution  is  added  to  an  absolutely  inactive  solution  of  tetanus 
toxin,  it  becomes  active  and  will  produce  tetanus. 

The  bacilli  multiply  at  the  seat  of  infection  and  there  produce  their  toxins. 
The  bacilli  themselves  have  been  demonstrated  in  the  circulating  blood  as  well  as 
in  the  sheaths  of  the  nerves  leading  from  the  wound  and  in  the  spinal  cord.  It  is 
generally  accepted,  however,  that  most  of  the  toxins  are  produced  at  the  primary 
focus  of  infection.  The  question  of  the  transmission  of  the  toxins  to  the  central 
nervous  system  has  been  the  subject  of  extensive  research,  and  has  an  important 
bearing  on  the  treatment.  The  toxins  have  been  repeatedly  demonstrated  in 
the  circulating  blood,  the  spinal  cord  and  medulla,  and  in  the  cerebro-spinal  fluid. 
*Elting:  Albany  Medical  Annals,  Jan.,  1904. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  455 

Morax,  Marie,  Meyer,  and  Ransom  have  shown  that  the  toxins  may  be  trans- 
mitted along  the  axones  of  the  peripheral  nerves  to  the  central  nervous  system. 
From  exhaustive  researches  Stintzing  has  concluded  that  the  transmission  may 
take  place  by  means  of  the  general  circulation,  but,  as  a  rule,  the  toxins  travel 
along  the  nearest  nerves,  and,  upon  reaching  the  spinal  cord,  produce,  first,  local 
tetanus,  and  then  the  toxms,  becoming  diffused  throughout  the  cord  and  medulla, 
produce  general  tetanus.  Elting  has  pointed  out  that  when  the  toxins  are  trans- 
mitted along  the  nerves  they  find  entrance  into  the  spinal  cord  at  the  points  of 
exit  of  the  nerves  and  affect,  first,  the  anterior-horn  cells.  However,  it  has  not 
as  yet  been  conclusively  proven  that  the  general  circulation  does  not  play  an  im- 
portant part  in  conveying  the  toxins  to  the  central  nervous  system,  and  there- 
fore it  must  still  be  considered  an  important  factor  in  the  etiology  of  the  disease. 

Senn  has  called  attention  to  the  resemblance  between  the  muscular  spasms 
caused  by  strychnine  poisoning  and  those  due  to  the  toxins  of  tetanus.  He  be- 
lieves that  if  this  and  other  drugs  can  act  upon  the  spinal  cord  in  such  a  manner 
as  to  cause  spasms  and  muscular  rigidity,  we  should  expect  that,  if  the  microbe 
of  tetanus  produces  toxins  in  the  tissues,  these  latter  might  produce  the  same 
effect  upon  the  cord,  and  that  the  symptoms  are  produced  by  them  and  not 
by  the  direct  action  of  the  microbe. 

Pathology. — Aside  from  the  presence  of  the  bacilli  and  the  toxins,  no  con- 
stant pathological  changes  take  place,  excepting  those  which  are  seen  in  the 
anterior-horn  cells  of  the  cord.  The  local  wound  may  show  a  mild  grade  of  in- 
flammation. When  a  mixed  infection  is  present  the  degree  of  inflammation 
seems  to  be  due  to  the  activity  of  micro-organisms  other  than  the  tetanus 
bacillus.  There  are  no  characteristic  lesions  of  the  nerve  trunks  and  nerve  cen- 
tres other  than  those  due  to  an  irritant  poison.  Minute  hemorrhages,  dilatation 
of  the  capillaries,  perivascular  exudation,  and  other  degenerative  changes  of  the 
nerve  cells  have  been  described.  Hyperemia  of  the  spinal  cord  and  medulla 
oblongata  frequently  occurs.  In  the  cord  the  anterior-horn  cells  are  most  con- 
stantly affected  and  show  degenerative  changes. 

Symptoms. — The  period  of  incubation  is  generally  accepted  to  be  from  eight 
to  fourteen  days.  Occasionally  it  is  much  shorter,  and  it  may  extend  over  three 
or  four  weeks. 

In  typical  cases  the  symptoms  usually  make  their  appearance  in  a  very 
gradual  manner.  There  is,  as  a  rule,  the  history  of  an  injury,  which  may  be 
very  slight  or  may  be  extensive.  Often  the  patient  is  presented  with  a  history 
of  having  stepped  on  a  rusty  nail,  or  of  having  run  a  splinter  into  the  foot,  or 
of  having  received  an  injury  from  a  toy  pistol.  In  a  little  over  a  week,  after  a 
comfortable  night's  rest,  the  patient  notices  a  slight  difficulty  in  masticating  his 
food  or  in  opening  his  mouth.  Some  authors  lay  much  stress  upon  the  occur- 
rence of  local  pain  and  slight  or  marked  spasms  of  the  muscles  in  the  region  of 
the  wound,  before  the  appearance  of  any  jaw  symptoms.    It  is  a  fact  that  this 


456 


AMERICAN  PRACTICE  OF  SURGERY. 


so-called  local  tetanus  occurs  in  all  cases  of  experimental  tetanus.  Cases  have 
been  observed  in  which  this  takes  place  also  in  man,  but,  as  a  rule,  the  patients 
come  to  the  clinician  onlj^  after  the  more  advanced  symptoms  have  made  their 

appearance.  The  occurrence  of 
local  tetanus  adds  weight  to  the 
theory  of  the  transmission  of  the 
toxins  along  the  motor  nerves. 
If  this  mode  of  transmission  is 
the  true  one,  the  local  spasms 
and  contractions  of  the  muscles 
would  be  explained,  the  trismus 
and  general  spasms  appearing 
when  the  toxins  have  been  con- 
veyed in  sufficient  quantities  and 
of  proper  concentration  to  the 
medulla  and  spinal  cord  by 
means  of  the  general  circulation. 
The  first  symptom  com- 
plained of  is  usually  that  of 
difficulty  in  opening  the  mouth. 
As  the  day  advances  this  stiff- 
ness of  the  jaw  increases,  and 
is  associated  with  pain  in  the 
cheeks  or  in  the  region  of  the 
temporo-maxillary  articulation. 
Motion  of  the  jaw  greatly  ■  in- 
creases the  pain.  An  examina- 
tion of  the  muscles  of  masti- 
cation will  reveal  a  rigidity  and 
prominence  of  the  masseter  mus- 
cles. There  is  no  soreness  or 
swelling  of  the  gums.  When  the 
patient  attempts  to  bend  the 
head  forward,  some  resistance 
will  be  noted  in  the  muscles  at 
the  back  of  the  neck.  The 
rotary  muscles  of  the  head  are 
not  affected.  At  the  same  time 
there  is  more  or  less  difficulty 
in  swallowing.  The  general  con- 
dition of  the  patient  is  normal. 

Fig.  135. — Chart  Showing    the    Temperature,    Pulse,  .  .  ,  . 

and  Respiratory  Curves  in  a  Typical  Case  of  Tetanus.  He  CVmCCS  nO  anxiety  aS   tO  hlS 


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INFECTIONS  OF  OCCASIONAL  OCCURRENCE. 


457 


condition.  As  the  disease  advances  the  contraction  of  the  masseter  muscles 
becomes  more  marlved,  and  the  question  of  ■  nutrition  becomes  a  serious  one. 
Attempts  to  feed  the  patient  by  mouth  may  increase  the  painful  spasm  of  the 
muscles.  The  face  may  assume  a  peculiar  expression,  the  "risus  sardonicus," 
due  to  spasms  of  the  facial  muscles.  But  involvement  of  the  orbicularis  oris 
and  other  muscles  of  expression  is  not  always  present. 

Already  on  the  second  day  the  jaws  may  be  firmly  locked.  The  stiffness  of 
the  neck  muscles  increases  markedly,  and,  in  consequence  of  the  spasm  of  these 
muscles,  the  head  will  be  drawn  backward.  The  patients  generally  have  a  good 
appetite,  but  cannot  eat.  They  complain  of  precordial  pain  and  some  gastric 
distress.  Gradually,  but  surely,  the  abdominal  muscles  become  involved.  Both 
recti  muscles  are  equally  contracted,  and  are  as  hard  as  iron.  The  spasms  are 
often  accompanied  by  intense  crampy  pain,  from  which  there  is  little  relief.  The 
patients  have  difficulty  in  emptying  the  bladder  and  rectimi.-  The  muscles  are 
in  a  state  of  tonic  contraction.  As  time  advances,  the  stiffness  of  the  neck  be- 
comes intensified  and  spreads  to  the  mus- 
cles of  the  back.  Sudden  noises,  or  at- 
tempts at  feeding,  or  the  slightest  irrita- 
tion, may  bring  on  paroxysmal  clonic 
spasms  affecting  different  groups  of  mus- 
cles. The  most  characteristic  is  that 
which  affects  the  muscles  of  the  back, 
producing  opisthotonus,  in  which  the 
spasm  may  be  so  severe  that  the  body 
forms  a  half-circle,  as  inflexible  as  iron, 
being  supported  on  the  occiput  and  heels. 
Or  the  anterior  pectoral  and  abdommal 
muscles  may  be  affected,  causing  empros- 
thotonus.  The  pain  at  such  times  is 
always  increased  and  the  patients  suffer 
excruciatingly. 

Varying  degrees  of  muscular  spasm 
may  be  present,  at  times  involving  only 
certain  groups  of  muscles.  ^^*^'  ^^^"'^• 

The  mind  is,  as  a  rule,  perfectly  clear,  and  there  is  no  impairment  of  the 
special  senses. 

In  the  most  acute  cases  the  advance  of  the  disease  is  very  rapid,  and  death 
may  occur  in  from  one  to  five  days. 

The  temperature  curve  throughout  the  disease  is  variable  and  not  character- 
istic. As  a  rule,  there  is  a  slight  rise  of  the  body  temperature,  which  does  not 
vary  much  during  the  twenty-four  hours.  As  the  end  approaches  there  is 
usually  a  steady  increase  in  the  temperature,  and  frec^uently  just  before  death 


dTse«e 

3 

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90° 
98° 
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Fig.    136. — Temperature    Curve    from  a 
Case  of  Very  Acute  Tetanus,  with  Rapidly 


458 


AMERICAN  PRACTICE  OF  SURGERY. 


there  is  hyperpyrexia,  the  temperature  reaching  107°,  108°  F.,  and  even  higher 
(Fig.  136).  In  many  cases  there  is  a  marked  post-mortem  rise,  and  cases  have 
been  reported  in  which  it  has  reached  113°  F.  In  the  very  acute  cases  hyper- 
pyrexia is  frequently  seen  (Fig.  135).  In  other  cases,  usually  of  the  subacute 
type,  the  temperature  may  remain  normal  throughout.  The  pulse  varies  with 
the  temperature,  excepting  in  the  afebrile  cases.  It  is  usually  increased  in  fre- 
quency, averaging  110  to  120  to  the  minute.  The  respiration  varies  with  the 
amount  of  involvement  of  the  respiratory  muscles. 

Rapid  emaciation  and  loss  of  strength  are  constant  symptoms.  As  death 
approaches  the  pulse  becomes  rapid  and  irregular,  and  the  end  may  come 
during  one  of  the  convulsive  attacks,  from  asphyxia  or  cardiac  dilatation,  or  the 


diseaTe 

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Fig.  137. — Temperature  Curve  of  a  Case  of  Tetanus,  Showing  the  Marked  Ante-mortem  and 
Post-mortem  Rises  in  Temperature. 

patient  may  die  of  exhaustion.  The  disease  may  prove  fatal  in  from  twenty-four 
to  forty-eight  hours,  or  the  suffering  may  be  prolonged  for  six  or  seven  days. 

In  the  cases  of  chronic  tetanus,  the  onset  of  the  disease  is  more  gradual  and 
the  symptoms  are,  as  a  rule,  not  so  severe.  The  incubation  period  may  last  for 
from  two  to  four  weeks.  The  most  constant  symptom  is  the  trismus,  which 
usually  is  not  so  marked  as  in  the  acute  cases,  and  allows  of  the  feeding  of  the 
patient.  The  symptoms,  however,  may  develop  as  rapidly  as  in  the  acute  eases, 
but  at  no  time  are  they  as  severe,  and  they  may  extend  over  a  period  of  from 
six  to  ten  weeks.  Prostration  is  marked  and  the  patients  usually  die  from 
marasmus  and  exhaustion. 

Tetanus  neonatorum  and  tetanus  puerperalis  are  really  subdivisions  of  tetanus 
traumaticus,  the  symptoms  of  which  have  already  been  described. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  459 

Tetanus  facialis,  hydrophobicus,  or  head  tetanus,  is  a  special  form  of  tetanus, 
following  injuries  to  the  head,  especially  wounds  of  the  face.  It  is  characterized 
by  paralysis  of  the  facial  nerve  on  the  side  of  the  lesion,  and  later  by  trismus  and 
spasms  of  the  muscles  of  deglutition.  Schultz  has  reported  a  very  interesting 
case  of  this  nature,  in  which  the  disease  was  caused  by  the  bite  of  a  peacock 
upon  the  forehead  of  the  patient.  Four  days  after  the  injury  the  first  symptoms 
developed,  and  consisted  of  a  paralysis  of  the  left  half  of  the  face.  On  the  eighth 
day  after  the  injury  the  tetanic  symptoms  developed,  and  were  confined  to  the 
muscles  of  the  right  side  of  the  face  and  those  of  the  head  and  neck.  Recovery 
took  place.  Tetanus  bacilli  were  demonstrated  in  the  tissues  of  the  wound. 
Most  of  these  patients  recover. 

Diagnosis. — As  a  rule,  the  diagnosis  is  easily  made.  In  many  cases  the  bacil- 
lus of  tetanus  may  be  isolated  from  the  wound.  The  cardinal  symptoms  are  the 
history  of  the  injury,  the  period  of  incubation,  the  spasm  of  the  masse ter  mus- 
cles, and  the  rigidity  of  the  neck.  It  may  be  differentiated  from  strychnine  poi- 
soning by  the  history  of  the  case,  the  lack  of  tonic  contraction  of  the  jaw  muscles, 
the  rapid  occurrence  of  clonic  spasms,  and  the  complete  relaxation  of  the  muscles 
between  the  paroxysms.  If  hydrophobia  is  suspected,  the  history  of  the  original 
wound  is  important.  In  hydrophobia  the  incubation  period  is  longer,  and  there 
are  present:  spasmodic  dysphagia,  dyspnoea,  an  absence  of  trismus  and  opisthot- 
onos (Butler),  and  more  mental  disturbance.  In  tetany  the  nature  of  the  spasm 
is  different,  and  it  usually  is  limited  to  the  extremities.     Trismus  rarely  occurs. 

Prognosis. — The  prognosis  is  always  grave,  but,  since  the  introduction  of 
antitetanic  serum,  treatment  of  the  disease  has  shown  more  favorable  results. 
Moschcowitz*  maintains  that  the  prognosis  depends  upon  two  things : 

(1)  The  period  of  incubation.  In  a  general  way,  the  shorter  the  period  of  in- 
cubation the  worse  is  the  prognosis.  This,  however,  is  dependent  on  the  second 
factor : 

(2)  The  rapidity  of  the  development  of  the  symptoms  and  their  severity. 

Puerperal  tetanus  and  tetanus  neonatorum  are  almost  always  fatal.  In  tet- 
anus facialis  and  in  those  cases  in  which  the  spasm  remains  localized  in  the 
head  and  neck  muscles,  the  prognosis  is  more  favorable. 

Treatment. — Of  greatest  importance  is  the  prophylactic  treatment  of  tetanus. 
In  many  cases  such  treatment  is  not  possible,  but  when  it  is  remembered  that 
more  than  half  the  cases  which  develop  in  the  United  States  are  due  to  wounds 
inflicted  by  a  rusty  nail  and  Fourth-of-July  casualties,  it  would  seem  that  too 
great  care  could  not  be  exercised  in  the  management  of  these  patients.  In 
such  wounds,  and  in  wounds  in  which  dirt  has  been  ground  into  the  tissues, 
especially  in  barnyard  injuries  and  in  those  which  have  been  inflicted  in  locali- 
ties where  tetanus  is  endemic,  the  strictest  antiseptic  precautions  should  be 
adopted  and  the  wound  treated  openly.     It  should  be  the  invariable  rule 

*  Annals  of  Surgery,  vol.  xxxii.,  p.  231. 


460  AMERICAN   PRACTICE   OF  SURGERY. 

that  in  such  cases  the  patient  shall  receive  an  injection  of  20  c.c.  or  more 
of  an  approved  antitetanic  serum.  This  rule  has  been  applied  in  many  in- 
stances and  with  the  most  brilliant  results.  It  is  the  writer's  opinion  that 
more  patients  have  been  prevented  in  this  way  from  acquiring  the  disease  than 
have  been  cured  by  the  use  of  the  serum  when  the  disease  had  become  well 
established. 

When  the  patient  is  presented  with  well-marked  or  beginning  sj^mptoms  of 
tetanus,  the  treatment  should  be  carried  out  in  a  routine  way.  The  indications 
are:  1st,  to  limit  the  local  activity  of  the  tetanus  bacillus;  2d,  to  neutralize  the 
toxins  which  have  been  produced;  3d,  to  eliminate  the  toxins  as  far  as  possible; 
4th,  to  nourish  the  patient;  and  5th,  to  control  the  convulsions. 

Local  Treatment. — In  small  wounds  it  may  be  possible  to  excise  the  entire 
area  of  pathological  tissue.  However,  in  most  cases  this  is  not  possible,  and  the 
wound  should  be  laid  open,  all  foreign  material  and  necrotic  tissue  should  be 
removed,  and  the  parts  should  be  thoroughly  cleaned  with  some  strong  antisep- 
tic solution.  Probably  the  two  best  solutions  to  be  employed  in  such  cases  are 
carbolic  acid  and  tincture  of  iodine,  and  they  should  be  freely  used.  Some 
writers  recommend  the  employment  of  the  thermocautery.  The  question  of 
amputation  of  the  member  which  is  the  seat  of  the  infection  must  be  decided  by 
the  individual  surgeon.  Some  favor  the  operation,  especially  where  there  has 
been  extensive  injury  to  a  part  or  where  suppuration  is  present;  others  believe 
that  it  is  useless,  holding  that  the  toxins  are  already  present  in  the  tissues  and 
circulating  blood  in  sufficient  quantities  to  cause  death,  and  that  consequently 
the  operation  would  do  more  harm  than  good. 

Tetanus  Antitoxin. — The  antitoxin  has  no  bactericidal  action.  It  protects 
only  against  the  tetanus  toxin.  It  is  to  be  regretted  that  no  standard  of  strength 
has  as  yet  been  obtained  in  the  production  of  the  tetanus  antitoxin,  and  there- 
fore the  dose  must  vary  with  the  preparation.  It  may  be  injected  subcutane- 
ously  or  intravenously,  and,  in  the  urgent  cases,  directly  into  the  brain,  or  by 
means  of  a  lumbar  puncture  subdurally.  Doses  of  from  5  c.c.  to  150  c.c.  of  the 
serum  have  been  injected  without  apparent  injury  to  the  patient.  As  a  routine 
procedure  it  is  well  to  inject  small  doses,  from  10  to  20  c.c.  of  the  serum,  sub- 
cutaneously  into  the  loose  cellular  tissue  of  the  back  or  abdomen,  and  repeat  it 
two  or  three  times  a  day.  In  the  more  severe  cases  lumbar  puncture  may  be 
done,  between  the  third  and  fourth  lumbar  vertebra?,  and,  after  allowing  from  10 
to  15  c.c.  of  cerebro-spinal  fluid  to  escape,  a  like  quantity  of  the  serum  is  injected. 
Kocher  has  recommended  injecting  10  c.c.  of  the  serum  into  the  lateral  ventri- 
cles of  the  brain.  This  may  be  repeated  every  day  and  combined  with  sub- 
cutaneous and  intravascular  injections.  Some  authors  recommend  that  very 
large  doses  of  the  serum  (200  to  300  c.c.)  be  injected  during  the  twenty-four 
hours.  The  most  important  thing  to  emphasize  is  the  necessity  of  injecting  the 
serum  as  soon  as  the  disease  is  suspected  or  recognized. 


INFECTIONS  OF  OCCASIONAL  OCCURRENCE.  461 

If  we  accept  the  theory  of  the  transmission  of  the  toxins  along  the  motor 
nerves  to  the  spinal  cord  as  the  true  one,  it  would  naturally  follow  that  an  injec- 
tion of  serum  directly  into  the  membranes  of  the  cord,  at  the  same  time  slightly 
abrading  the  nervous  tissue,  would  be  apt  to  be  followed  by  more  rapid  results, 
in  that  the  serum  would  more  rapidly  come  into  contact  with  the  toxins  affecting 
the  anterior-horn  cells.  It  has  furthermore  been  demonstrated,  with  a  certain 
degree  of  certainty,  that  the  toxins  cannot  travel  in  a  peripheral  direction  along 
the  motor  nerves,  and  that  it  takes  several  days  for  the  toxins  to  travel  from  the 
end  of  a  nerve  to  its  origin;  also  that  antitoxin  pursues  exactly  the  same  course. 
Accepting  these  theories,  Rogers*  has  advocated  a  combined  intraneural  and 
intraspinal  injection  of  serum,  a  procedure  which  he  has  carried  out  successfully 
in  two  cases.  In  the  first  case,  in  which  tetanus  followed  an  injury  to  the 
hand,  he  injected  into  each  one  of  the  nerves  of  the  left  brachial  plexus  five  to 
ten  minims  of  antitoxin.  In  addition  to  this,  sixty  minims  were  injected  into 
the  spinal  cord.  This  was  repeated  the  following  day.  In  his  second  case,  fol- 
lowing an  injury  to  the  foot,  he  exposed  the  anterior  crural  and  sciatic  nerves 
on  the  right  side  and  injected  into  each  half  a  drachm  of  antitoxin,  combined 
with  a  spinal  injection  of  one  drachm  and  a  half  of  serum.  The  spinal  injec- 
tion was  repeated  on  three  successive  days.    Both  patients  recovered. 

Carbolic-acid  Treatment. — This  method  of  treatment  may  be  used  independ- 
ently or  combined  with  the  serum  and  drug  treatment.  It  was  first  advocated 
by  Bacelli,  who  noted  that  injections  of  carbolic  acid  were  followed  by  a  marked 
diminution  of  the  reflex  excitability  of  the  nervous  system,  and  he  has  ascribed 
to  it  certain  general  antiseptic  properties.  The  amount  of  the  solution  which 
should  be  injected  varies  according  to  different  experimenters.  Kocher  recom- 
mends the  systematic  subcutaneous  injection  of  carbolic  acid,  in  doses  of  rr[xv. 
of  a  three-per-cent  solution  every  one  or  two  hours,  according  to  the  severity  of 
the  case.  According  to  Elting  {loc.  cit.),  Ascoli  in  one  case  injected  72  c.c.  a 
day  for  ssven  days,  and  60  c.c.  a  day  for  forty-one  days.  Symptoms  of  car- 
bolic-acid poisoning  have  never  been  observed  in  cases  so  treated.  It  should  be 
tised  as  a  routine  treatment  in  all  severe  cases. 

Drug  Treatment. — Drugs  are  indicated  to  control  the  symptoms,  especially 
for  the  prevention  and  relief  of  spasms.  Opiates  may  be  administered  freely. 
Morphine  should  be  given  by  hypodermic  injections,  alternating  with  large  doses 
of  chloral  hydrate  and  the  bromides  given  per  rectum.  To  control  the  more 
severe  spasms  chloroform  should  be  given  temporarily,  especially  where  there  is 
much  dyspnoea.    Amyl-nitrite  pearls  may  be  called  for  in  spasm  of  the  glottis. 

To  sustain  the  patient  and  contribute  to  the  circulating  fluids,  as  well  as  to 
dilute  the  toxins  and  aid  in  their  elimination,  subcutaneous  infusions  of  deci- 
normal  salt  solution  should  be  given. 

Nourishment. — From  the  onset  of  the  symptoms  this  becomes  an  important 
*  Annals  of  Surgerj^,  vol.  xL,  pp.  417,  759. 


462  AMERICAN  PRACTICE  OF  SURGERY. 

question,  and  systematic  and  regular  feeding  should  be  prescribed.  In  the  milder 
cases  small  amounts  of  highly  nutritious  food  may  be  given  by  the  mouth. 
When,  however,  it  is  impossible  to  administer  food  in  this  manner,  or  when  the 
act  of  swallowing  becomes  too  painful  or  impossible,  regular  nutrient  enemata 
should  be  given  per  rectum,  supplemented  by  subcutaneous  injections  of  §iij.- 
vi.  of  oil,  as  suggested  by  Leube. 

In  the  general  management  of  the  case,  careful  nursing  and  absolute  quiet 
are  essential.  The  patient  should  be  isolated  in  a  dark  room,  as  far  removed  as 
possible  from  any  noise.  Sudden  draughts  of  air  and  many  seemingly  slight 
external  stinmli  tend  to  produce  spasms. 


SURGICAL  SHOCK. 

BY  JOSEPH  C.  BLOODGOOD,  M.D.,  Baltimore,  Maryland,. 


.  This  subject  is  one  of  surgical  physiology.  At  the  present  time  the  exact 
etiological  factors  are  not  definitely  and  conclusively  proven.  It  is  by  no 
means  a  simple  problem  to  investigate,  either  experimentally  in  the  physiolog- 
ical laboratory  or  clinically  in  surgical  practice. 

For  practical  purposes,  shock  should  be  considered  a  condition  of  general 
depression  produced  by  various  causes.  These  factors  act  through  the  me- 
dium of  afferent  nerves  upon  various  centres  in  the  spinal  cord  and  brain, 
especially  the  vasomotor  centres.  Howell,  from  his  physiological  experiments, 
recognizes  a  cardiac  shock  as  well  as  a  vasomotor  shock.  It  is  a  question 
whether  the  sympathetic  ganglia  are  also  deleteriously  influenced  by  the  vari- 
ous factors  which  may  produce  shock. 

In  this  condition,  which  we  call  shock,  there  is  always  a  fall  in  the  blood 
pressure,  but  a  fall  in  the  blood  pressure  alone  should  not  be  considered  a 
positive  indication  of  shock.  All  of  the  nerve  centres  react  feebly  to  afferent 
stimuli,  the  pulse  is  usually  rapid  and  feeble,  the  respiration  shallow,  the  pupils 
somewhat  dilated,  reacting  feebly  to  light;  all  of  the  cutaneous  reflexes  are 
lessened;  there  is  increased  perspiration,  for  which  reason  the  skin  feels  cold 
and  moist;  the  temperature  of  the  body  is  lowered;  the  mental  condition  is 
usually  one  of  quiet  depression,  if  I  may  use  this  term;  there  is  at  first  no  delir- 
ium, nor  delusions.  All  the  mental  faculties  are  less  acute,  but  the  patient, 
nevertheless,  is  perfectly  conscious.  There  is  no  pain  or  discomfort,  but  the 
patient  realizes  his  depressed  condition  and  will  inform  you  that  he  feels  weak. 

At  the  present  time  it  is  impossible  to  define  shock,  chiefly  because  its  exact 
physiology  has  not  been  completely  worked  out.  For  this  reason  we  must 
use  the  term  in  a  composite  sense  for  a  clinical  picture  which  varies  in  degree, 
and  is  produced  by  various  factors,  some  of  which  we  understand  and  can  de- 
monstrate, many  of  which  apparently  we  do  not  understand.  Future  experimen- 
tal physiological  work  and  more  exact  clinical  observation  with  instruments  of 
precision  may  simplify  the  question  and  allow  us  to  classify  shock  according 
to  the  exact  factor  or  factors  which  produce  it.  We  may  also  be  able  to  define 
and  recognize  different  clinical  pictures  in  relation  to  different  etiological  factors. 

For  this  reason  a  discussion  of  the  subject  must  be  limited.  One  can  only 
present,  first,  the  results  of  physiological  experimental  work  which  are  suf- 

463 


464  A]iIERICAX   PRACTICE   OF  SURGERY. 

ficieutly  accurate  to  allow  conclusions  for  practical  purposes  in  the  clinical 
recognition  and  treatment  of  shock,  and  to  discuss  the  c^uestion  from  a  purely 
practical  and  clmical  standpoint  only  so  far  as  we  are  ciuite  positive  of  the 
accuracy  of  our  observations  and  experience. 

In  man  and  animals  after  death  from  shock  the  gross  and  microscopic 
changes,  with  our  present  means  of  estimating  them,  are  practically  nil.  One 
finds  that  the  blood  is  accumulated  chiefly  in  the  veins,  especially  of  the  splanch- 
nic system. 

THE  PHYSIOLOGY  OF  SHOCK. 

Schaefer  ("Text-book  of  Physiology,"  1900,  vol.  ii.,  p.  845)  states  that  shock, 
like  collapse,  is  a  term  more  used  by  the  clinician  than  the  physiologist,  and 
that  it  is  a  term  somewhat  ill  defined  in  its  scope.  By  the  physiologist  "shock" 
is  understood  to  be  primarily  a  nervous  condition.  "If  in  a  frog  the  spinal 
marrow  be  divided  just  behind  the  occiput,  there  are  for  a  very  short  time 
no  diastaltic  actions  in  the  extremities;  the  diastaltic  actions  speedily  return; 
this  phenomenon  is  shock."  By  diastaltic  action  is  meant  the  muscular  move- 
ments of  the  extremities  which  take  place  after  stimuli.  Shock  may  be  con- 
sidered, according  to  the  physiologist,  the  whole  of  that  depression  or  suppression 
of  the  nervous  function  which  ensues  forthwith  upon  a  mechanical  injurj^  of 
some  part  of  the  nervous  system  and  is  of  a  temporary  nature  (Schaefer). 
Physiologists,  therefore,  are  somewhat  imcertain  whether  the  phenomenon  of 
shock  should  be  considered  one  of  depression  or  of  inhibition.  In  animals,  spinal 
shock  is  a  distinct  plienomenon.  One  makes  a  section  of  the  spinal  cord,  the 
spinal  reflexes  disappear,  but  to  reappear,  although  the  spinal  cord  be  still 
divided.  That  is,  the  mechanical  injury  produced  m  dividmg  the  spinal  cord 
affects  temporarily  the  centres  below  in  such  a  waj'  that  for  a  certam  time 
they  do  not  react  to  stimuli,  yet  these  centres  themseh'es  have  received  no 
mechanical  traumatism.  My  careful  reading  of  the  physiologists'  desciiption 
of  spinal  shock  has  given  me  a  better  conception  of  surgical  shock,  which  may 
be  correct.  Surgical  shock  is  associated  with  mechanical  injuries  in  various 
parts  of  the  body,  near  or  remote  from  various  nervous  centres;  these  cen- 
tres are  affected  by  afferent  stimuli,  either  of  a  depressing  or  of  an  inhibitory 
nature;  the  result  is  that  these  centres  do  not  react  at  all,  or  react  less 
promptly  for  a  certain  period  of  time.  In  some  instances  the  effect  on  the  centre 
is  sufficient  to  prevent  it  from  reacting  for  such  a  length  of  time  that,  if  it  is 
one  of  the  so-called  vital  centres  in  the  medulla,  death  takes  place. 

It  has  been  my  good  fortune  to  be  able  to  discuss  the  physiological  problems 
of  shock  with  Dr.  Howell,  professor  of  physiology  of  the  Johns  Hopkins  Uni- 
versity, and  to  read  the  original  manuscript  of  a  paper  entitled  An  Experi- 
mental Study  of  the  Cause  of  Shock,"  which  was  written  quite  recently.  The 
chief  virtue,  therefore,  of  my  remarks  on  the  physiology  of  this  subject  is  due 


SURGICAL  SHOCK.  465 

to  the  source  of  my  information.  I  have  had  no  practical  experience  in  the 
physiological  laboratory.  According  to  Howell  there  is  some  uncertainty  as 
to  the  immediate  physiological  cause  of  surgical  shock.  In  the  human  indi- 
vidual the  mental  and  physical  symptoms  of  shock  would  indicate  a  marked 
depression  of  the  activity  in  the  nerve  centres,  and  not  infrecjuently  these 
symptoms  increase  in  severity  and  terminate  in  death. 

In  observations  on  lower  animals,  this  condition  is  associated  not  only  with 
a  faint  and  rapid  heart-beat,  but  with  a  pronounced  and  permanent  fall  in 
the  blood  pressure. 

The  relation  of  a  fall  in  the  blood  pressure  to  shock  is  such  an  important 
one  that  I  will  give  Howell's  remarks  in  detail  and  verbatim,  rather  than  attempt 
to  summarize: 

"Since  this  latter  symptom  (the  fall  in  blood  pressure)  is  sufficient  in  itself 
to  explain  many,  if  not  all,  of  the  other  features  exhibited  in  shock,  it  has  been 
seized  upon  as  the  reall}'  significant  and  causative  factor.  The  condition  of 
an  animal  in  extreme  shock  is  m  fact  similar  to  that  of  an  animal  whose  vaso- 
motor centre  has  been  destroyed  or  has  been  severed  from  its  connections  with 
the  blood-vessels.  Under  both  conditions  the  complete  paralysis  of  the  blood- 
vessels results  in  a  fall  of  the  blood  pressure  to  40  to  20  mm.  of  mercury  and  a 
rapid,  feeble  heart-beat;  and  unless  in  some  way  the  vascular  tone  is  restored 
or  the  force  of  the  heart-beat  is  increased,  the  circulation  soon  becomes  more 
and  more  feeble  and  finally  ceases.  While  the  activities  of  the  other  nerve 
centres,  particularly,  as  will  be  shown,  that  controlling  the  heart,  may  also 
be  depressed  primarily  in  shock,  the  failure  of  the  vasomotor  centre  with  the 
subsequent  vascular  dilatation  and  fall  of  blood  pressure,  seemed  to  be  suf- 
ficient in  itself  to  lead  to  a  fatal  termination,  and  this  symptom  may,  there- 
fore, be  regarded  as  the  most  essential  and  most  dangerous  feature  of  shock. 
In  surgical  experience  and  in  experimental  observations  it  is  noticed  that 
what  we  call  shock  may  exist  in  very  different  degrees  of  severity.  It  may 
be  light  and  comparatively  transient,  or  severe  and  fatal,  or  severe  with  rapid 
or  slow  recovery.  How  the  blood  pressure  varies  under  the  different  conditions 
in  man  has  not  as  yet  been  determined  with  accuracy,  but  m  experiments  on 
lower  animals  it  seems  quite  certain  that  permanent  recovery,  when  it  occurs, 
follows  upon  the  restoration  of  blood  pressure  to  normal  limits.  It  would  seem 
justifiable,  therefore,  to  connect  the  varying  degrees  of  severity  of  shock  with 
the  duration  and  extent  of  the  vascular  paralysis.  Vascular  dilatation,  how- 
ever, is  a  normal  physiological  occurrence,  and,  under  strictly  functional  con- 
ditions, it  may  be  sufficiently  extensive  to  cause  a  distinct  fall  in  blood  pressure ; 
while  under  experimental  conditions,  as  every  physiologist  knows,  we  may 
in  various  ways  obtain  a  very  marked  fall  in  blood  pressure  in  consequence 
of  vascular  dilatation.  Stimulation  of  depressor-nerve  fibres,  in  the  depressor 
nerve  from  the  heart,  for  instance,  or  in  the  nerves  from  other  regions,  such 
VOL.  I. — 30 


466  AMERICAN  PRACTICE  OF  SURGERY. 

as  the  ear  or  testes,  will  bring  about  such  a  vascular  dilatation.  We  do  not, 
of  course,  .speak  of  a  fall  of  pressure  produced  in  this  Avay  as  a  condition  of 
shock.    The  effect  passes  off  promptly  as  soon  as  the  stimulus  ceases. 

"  When  Crile,  therefore,  in  his  recent  work  on  surgical  shock,  makes  the  state- 
ment that  '  the  essential  phenomenon  in  shock  is  a  diminution  of  blood  press- 
ure,' his  words,  unless  properly  qualified,  are  erroneous  and  misleading.  To 
call  every  diminution  in  pressure  a  condition  of  shock  amoimts  to  giving  a  new 
meaning  to  the  term  and  is  tantamount  to  saying  that  shock  is  a  constant 
and  normal  occurrence  in  the  functional  activity  of  the  bodJ^  We  have  reason 
to  believe  that  a  state  of  syncope  may  be  due  to  a  sudden  and  large  fall  of  blood 
pressure,  but  even  such  an  extreme  and  abnormal  variation  is  not  properly 
regarded  as  shock,  since  recovery  is,  as  a  rule,  prompt  and  complete.  If, 
therefore,  we  say  that  the  most  important  symptom  of  shock  is  a  more  or  less 
complete  paralysis  of  vascular  tone,  we  must  set  certain  limits  to  the  extent 
and  especially  to  the  duration  of  this  paralysis,  and  designate  the  condition 
as  one  of  shock  only  when  it  passes  beyond  these  limits.  Under  experimental 
conditions  we  recognize  the  fact  that  in  extreme  shock  the  vascular  paralysis 
is  as  absolute  as  it  would  be  were  every  vaso-constrictor  fibre  in  the  body 
divided  or  the  vaso-constrictor  centre  destroyed.  Between  this  condition 
and  that  of  fmictional  vascular  dilatation  with  slight  fall  of  blood  pressure 
we  may  presumably  have  every  degree  of  variation,  but  we  are  not  justified 
in  using  the  term  shock  except  in  those  cases  in  which  the  vascular  paralysis 
is  not  only  extensive,  but  is  maintained  for  a  long  period  after  the  original 
stimulus  causing  it  has  ceased  to  act.  It  should  be  added,  perhaps,  that  in 
what  precedes  I  have  not  taken  into  consideration  the  shock  that  may  be  pro- 
duced solely  by  severe  hemorrhage.  That  a  great  loss  of  blood  should  bring 
about  a  fall  in  blood-pressure  and  a  diminution  in  the  activity  of  the  heart 
and  central  nervous  system  is,  so  to  speak,  self-evident  and  needs  no  attempt 
at  explanation.  We  are  concerned  here  only  with  those  conditions  in  shock 
in  which  the  hemorrhage  alone  is  not  sufficient  to  explain  the  result,  and  can 
only  be  regarded  as  an  adjunct  factor.  If  we  grant  the  essential  correctness 
of  the  general  statements  made  above,  it  is  evident  that  two  main  problems 
confront  us.  First,  what  is  the  immediate  cause  of  the  profound  and  prolonged 
vascular  paralysis,  and,  second,  what  means  may  be  used  to  restore  the  blood- 
vessels to  their  normal  tone?  Experiments  that  I  have  made  recently  throw, 
I  believe,  some  light  upon  these  problems,  and  have  led  me  to  take  a  point  of 
view  somewhat  different  from  that  usually  assumed  in  disciissing  the  causa- 
tion of  shock.  The  experiments  were  made  upon  dogs,  and  shock  was  produced 
by  one  of  the  following  methods:  1.  Exposure  and  handling  of  the  abdominal 
viscera;  2.  Long-continued  sthmdatioyi  of  the  cutaneous  nerves,  effected  usually 
by  the  application  of  hot-water  bags  to  the  skin;  3.  By  operations  on  the  brain 
involving  removal  of  a  portion  of  the  skull  and  dura,  and  in  some  cases  also 


SURGICAL  SHOCK.  467 

of  the  cerebrum.  It  should  be  added  that  in  all  cases  the  dogs  were  completely 
an£esthetized  with  morphia  and  ether.  'Whether  ansesthetization  with  ether 
aids  or  retards  the  production  of  shock  cannot  be  stated  definitely,  but  in 
human  beings  shock  from  operations  under  ether  occurs  often  enough,  and 
in  dogs  under  ether  the  vasomotor  reflexes  at  least  would  indicate  a  favorable 
condition  for  shock.  However  this  VL\&y  be,  it  was  my  experience,  as  it  has 
been  that  of  other  observers,  that  the  production  of  shock  in  dogs  is  a  very  uncer- 
tain matter.  In  some  cases  it  comes  on  after  comparatively  little  operative  vio- 
lence, while  in  other  cases  prolonged  operations,  wide  exposure  of  the  abdominal 
viscera,  fall  of  body  temperature,  and  some  hemorrhage  might  fail  to  induce 
shock.  In  such  negative  cases  the  vasomotor  reflexes,  as  will  be  explained 
presently,  indicate  that  the  animal  was,  so  to  speak,  approaching  a  condition 
of  shock. 

"Of  the  several  methods  that  I  used  the  one  that  caused  shock  most  prompt- 
ly and  most  frequently  was  operation  on  the  brain.  In  some  cases  mere  expos- 
ure of  the  brain  produced  complete  shock,  while  in  other  cases,  after  removing 
a  portion  of  the  skull,  the  animal  still  showed  a  normal  pressure,  but  fell  into 
shock  more  or  less  rapidly  after  ablation  of  portions  of  the  cerebrum.  The 
animals  were,  in  all  cases,  connected  with  the  kymograph,  and  records  were 
taken  continuously  of  the  blood  pressure  and  respiration.  Some  of  the  details 
of  these  experiments  have  been  published  already  "  Contributions  to  Medical 
Research'  dedicated  to  Victor  C.  Vaughan),  and  it  may  suffice  to  give  here  a 
summary  of  these  results  and  my  conclusions : 

Howell's  Conclusions  on  Shock.—"  l.  Shock  is  characterized  by  a  long-con- 
tinued, low  arterial  pressure  (vascular  shock)  due  to  partial  or  complete  loss 
of  activity  of  the  vaso-constrictor  centre,  and  by  a  rapid,  feeble  heart-beat 
(cardiac  shock)  due  in  part,  at  least,  to  a  partial  or  complete  loss  of  activity 
of  the  cardio-inhibitory  centre. 

2.  Cardiac  shock  may  occur  more  or  less  Independently  of  vascular  shock, 
but  vascular  shock  is  always  preceded  or  accomjjanied  by  cardiac  shock.  The 
respirations  in  shock  are  diminished  in  amplitude  and  usually  in  rate. 

3.  Shock  may  be  produced  experimentally  by  severe  operations  of  various 
kinds,  but  most  often  by  extensive  operations  on  the  brain. 

"  4.  The  physiological  evidence  in  experimental  shock  indicates  that  the 
condition  is  due  fundamentally  to  a  strong  inhibition  of  the  medullary  centres 
(vaso-constrictor,  cardio-inhibitory),  leading  to  a  long-continued  suspension  of 
activity,  partial  or  complete. 

5.  Injections  of  alkaline  solutions  of  sodium  carbonate  intravenously  or 
into  the  rectum  during  shock  increase  markedly  the  amplitude  of  the  heart- 
beat and  bring  about  a  rise  of  arterial  pressure.  When  the  shock  is  moderate 
(aortic  tension  60  to  70  mm.  Hg)  the  injections  maj^  restore  arterial  pressure 
to  an  approximately  normal  level.    WJien  the  shock  is  severe  (aortic  tension 


468  AMERICAN  PRACTICE  OF  SURGERY. 

of  20  to  40  mm.  Hg)  the  injections  ma}'  increase  arterial  pressure  by  about 
100  per  cent  for  long  intervals,  and  the  effect,  when  it  wears  off,  ma}'  be  restored 
by  repeating  the  injections.  The  effect  of  the  injections  is  due  chiefly  or  entirely 
to  a  direct  action  on  the  heart. 

6.  Stimulation  of  sensory  nerve  trunks  or  sensory  surfaces  in  an  animal 
in  a  condition  of  shock  leads  to  a  further  fall  of  pressure,  and  to  this  extent 
augments  the  condition  of  shock. 

7.  The  blood  of  animals  in  a  condition  of  shock  has  no  toxic  action  when 
injected  into  the  circulation  of  a  normal  animal." 

Blood  Pressure. — At  the  present  time  our  only  accurate  method  of  estimat- 
ing shock,  either  in  the  phj'siological  experiment  or  in  surgical  practice,  is  by 
.means  of  an  apparatus  which  records  the  blood  pressure.  This  is  not  the  place 
to  discuss  the  relative  values  of  the  different  contrivances  used  for  this  purpose. 
Howell  and  other  physiologists  are  of  the  opinion  that  it  is  of  the  greatest 
importance  to  employ  an  apparatus  which  records  both  the  diastolic  and  sys- 
tolic pulse  waves.  Unfortunately,  at  the  present  time  there  is  neither  in 
the  literature  nor  in  the  experience  of  the  surgical  clinic  with  which  I  am  con- 
nected a  sufficient  number  of  these  accurate  blood-pressure  records  in  surgical 
cases  to  allow  any  positive  conclusions  as  to  their  practical  value.  I  am  of 
the  opinion,  however,  that  this  instrument  of  precision  should  be  employed 
more  frequently  in  surgical  cases,  and  I  would  suggest  to  those  interested  in 
this  subject  to  read  the  contributions  of  Erlanger  and  Hooker  published  in 
the  Johns  Hopkins  Hospital  Reports  (vol.  xii.,  1904),  entitled  "An  Experimental 
Study  of  Blood-Pressure  and  Pulse-Pressure  in  Man,"  and  the  literature  which 
I  ha-\-e  discussed  in  Progressive  Medicine  for  December,  1903,  and  December, 
1905. 

Physiological  Experiments  to  Estimate  the  Effect  of  Various  Manipulations, 
During  Operation,  on  Blood Pressxire,  and  Their  Relation  to  Shock. — The  practical 
surgeon  should  have  knowledge  of  the  following  data :  The  effect  of  the  general 
narcotic  on  blood  pressure  and  its  relation  to  shock;  whether  in  certain  opera- 
tions shock  is  less  if  the  operation  is  carried  on  under  spinal  or  local  anfesthesia  ; 
the  effect  of  hemorrhage,  the  duration  of  the  operation,  exposure  of  tissues 
to  the  air,  effects  of  extreme  heat  or  cold,  the  effect  of  manipulation  or  uijury 
on  various  tissues  or  organs. 

For  these  data  Crile,  of  Cleveland,  has  without  doubt  published  the  most 
important  contributions,  and  I  shall  draw  largely  upon  his  two  works :  '  Surgi- 
cal Shock  "  published  by  the  Lippincott  Company  in  1899,  and  "  Blood-Press- 
ure in  Surgery  "  published  by  the  same  firm  in  190.3. 

We  may  summarize  the  results  of  this  experimental  work  as  follows: 
Hemorrhage  is  one  of  the  most  important  factors  in  the  production  of  shock. 
As  it  is  practically  mider  the  control  of  the  sm'geon,  this  element  can  in  the 
majority  of  cases  be  eliminated  by  painstaking  hsemostasis.     A  long  bloodless 


SURGICAL   SHOCK.  469 

operation  is  mucli  less  serious  tlian  a  short  and  blood}^  one.  A  general  anses- 
thetic  must  be  considered  in  all  cases  a  factor.  The  significance,  however, 
of  this  factor  varies.  Chloroform  is  always  associated  with  a  fall  in  blood 
pressure,  ether  with  a  rise  in  blood  pressure. 

Gentle  manipulation  and  incision  of  tissues  with  a  sharp  knife  affect  the 
blood  pressure  less  than  rough  manipulation  and  tearing  of  tissues.  The  greater 
the  nimiber  of  afferent  sensory  nerves  in  the  tissue  manipulated,  the  greater 
the  effect  on  the  vasomotor  centres.  These  experimental  findmgs  are  well 
borne  out  by  clmical  observations.  During  an  operation,  therefore,  the  amoimt 
of  the  anaisthetic  should  be  as  small  as  possible;  the  operation  should  be  per- 
formed as  quickly  as  is  compatible  with  the  safety  of  the  patient  and  the  pur- 
pose of  the  intervention;  tissues  should  be  handled  as  gently  as  possible;  if  large 
nerves  must  be  divided,  as  in  amputations,  they  should  be  blocked  with  cocaine 
injection;  tissues  should  be  exposed  to  the  air  only  when  absolutely  necessary; 
they  should  then  be  protected  with  warm  moist  gauze;  the  patient  should  not 
be  exposed  to  extreme  degrees  of  heat  or  cold. 

The  weaker  the  patient  to  he  subjected  to  operation,  the  more  attention  must  he 
given  to  these  details  xrhich  lessen  shock. 

Skin. — Simple  incision  of  the  skin  has  practically  no  effect  upon  blood 
pressure ;  burning  of  the  skin  causes  a  uniform  rise  in  the  pressure.  The  effect 
is  more  marked  in  animals  when  the  skin  of  the  paws  is  burnt.  All  Crile's 
observations  tend  to  show  that  the  greater  the  nerve  supply  of  the  area  of 
skin  the  greater  the  shock  when  this  area  is  subjected  to  injury.  The  relation 
of  extensive  skin  injuries  to  shock  is  well  illustrated  in  burns.  The  wider  the 
area  of  a  skin  burn  the  greater  the  shock ;  the  depth  of  the  burn  is  not  a  factor. 
In  a  superficial  burn  there  is  just  as  much  injury  to  nerve  ends  as  in  the  deep 
burn.  Undoubtedly  in  burns  there  is  another  factor  in  the  cause  of  death, 
besides  the  tremendous  effect  on  the  vasomotor  centres  from  the  extensive 
peripheral  irritation — that  is,  the  effect  of  the  toxins  undoubtedly  produced 
in  the  burnt  tissue. 

Pain  in  the  normal  individual  produces  a  rise  in  the  blood  pressure;  but 
when  we  are  dealing  with  weakened  organisms  or  a  patient  already  shocked, 
pain  is  an  afferent  impulse  which  has  a  decided  depressing  effect  on  the  medul- 
lary centres.  For  this  reason,  in  the  treatment  of  such  patients  everything 
should  be  done  to  prevent,  lessen,  or  block  it.  In  such  cases  a  skin  incision 
without  an  ana?sthetic  becomes  an  element  which  increases  shock,  and  the 
danger  of  the  antesthetic  is  less  than  the  danger  of  the  painful  incisions  or  ma- 
nipulation. It  recjuires  a  deep  narcosis  with  a  general  anaesthetic  to  mhibit 
the  painful  effect  of  a  skin  incision.  For  this  reason,  when  on  accoimt  of  the 
weakened  condition  of  the  patient,  or  in  the  presence  of  shock,  one  does  not 
wish  to  produce  a  deep  general  narcosis,  the  operation  should  be  performed 
under  a  combination  of  local  and  general  ana?sthesia.    The  skin  incision  can  be 


470  AMERICAN  PRACTICE  OF  SURGERY. 

made  perfectly  well  under  the  infiltration  method  of  Schleich,  the  deeper  incision 
by  peri-  or  intraneural  injections :  further  manipulations  under  general  narcoses. 

This  demonstrates  how  important  it  is  for  the  surgeon  to  be  familiar  with 
the  sensitiveness  of  different  tissues.  This  knowledge  is  not  only  of  value 
when  performmg  operations  under  local  ana>sthesia,  but  in  preventing  shock 
by  antesthetizing  with  a  local  or  general  anaesthetic  the  sensitive  tissues.  Len- 
nander's  publications  on  this  subject  {Mittheilimgen  a.  d.  Grenzgeb.  der  Chir. 
vnd  Med.,  1902,  vol.  x.,  and  Deutsche  Zeitschr.  f.  Chir.,  1904,  vol.  Ixxiii.,  p. 
297,  and  Mittheilungen  a.  d.  Grenzgeb.  d.  Chir.  u.  Med.,  1906,  vol.  xv.)  are  the 
most  recent  and  the  best. 

Connective  Tissue. — Crile  was  unable  to  find  any  effect  of  injury  to  this 
tissue,  providing  nerves  were  not  included. 

Muscle. — The  effect  of  tearing  and  crushing  of  muscles  was  attended  by 
practically  the  same  phenomena  as  those  observed  from  similar  manipulations 
of  the  skin,  but  to  a  very  much  lesser  degree.  Lennander  did  not  investigate 
the  sensibility  of  muscles.  In  my  own  experience  with  operations  under  local 
auEDsthesia  I  found  that  the  muscle  is  not  sensitive.  However,  the  nerve  near 
or  within  the  muscle  is  very  sensitive.  For  this  reason,  in  operations  under 
local  anaesthesia,  one  must  be  familiar  with  the  position  of  the  various  nerves 
so  that  they  may  be  rendered  ansesthetic  by  neural  or  intraneural  injections. 
In  cases  of  amputation  on  patients  suffering  from  shock  I  am  inclined  to  the 
opinion  that,  if  possible,  one  should  avoid  division  through  large  muscle  bellies; 
instead,  he  should  select  if  possible  the  joint  or  a  position  where  most  of  the 
muscles  are  tendinous. 

Bone. — According  to  Lennander  the  marrow  and  the  cortical  bone  are 
insensitive,  while  the  periosteum  is  very  sensitive.  Crile's  experimental  work 
confirms  this  finding.  I  am  of  the  opinion  that  the  rapid  sawing  of  a  bone 
would  be  attended  with  very  little,  if  any,  shock.  It  is  very  easy,  however, 
to  render  the  periosteum  insensible  with  cocaine  infiltration.  I  have  repeat- 
edly resected  one  or  more  ribs  painlessly  after  this  method  in  patients  in  a 
very  critical  condition,  with  empyema  or  lung  gangrene. 

Joints. — According  to  Lennander's  most  recent  communication  (Mitthei- 
lungen a.  d.  Grenzgebieten  d.  Med.  u.  Chir.,  1906,  vol.  xv.,  p.  465)  the  joint  cap- 
sule has  sensory  nerves,  but  the  articular  cartilage  is  insensible.  Crile  was 
unable  to  demonstrate  any  deleterious  effects  from  various  manipulations  on 
large  joints.  Under  local  anaesthesia  I  have  been  able  to  open  and  irrigate 
without  much  pain  most  of  the  joints.  Ai'thritis  increases  the  sensitiveness 
of  the  surrounding  tissues.  Dislocations  and  compound  injuries  of  the  joints 
are  not  associated  with  any  considerable  degree  of  shock  unless  the  soft  parts 
and  nerves  in  the  neighborhood  are  injured. 

Nerve  Trunks. — Crile's  experimental  work  demonstrated  that  the  greatest 
effect  upon  blood  pressure  was  produced  by  injuries  of  nerve  trunks.     A  quick 


SURGICAL  SHOCK.  471 

severing  with  a  sharp  instrument  had  much  less  effect  than  crushing  or  tear- 
ing. The  effect  on  the  centres  from  injuries  to  nerve  trunks  can  be  entirely 
inhibited  by  a  local  infiltration  of  cocaine  centrally  to  the  point  of  injury. 
This  laboratory  experiment  is  confirmed  by  quite  a  number  of  clinical  obser- 
vations. In  amputations,  especially  if  the  patient  be  in  a  condition  of  shock, ' 
the  large  nerve  trunks  should  be  blocked. 

Operations  upon  the  Head. — In  operations  upon  the  brain,  incision  of  the  scalp 
and  the  making  of  a  bone  flap  are  attended  with  little  effect  upon  the  blood 
pressure,  but  exposure  and  manipulation  of  the  dura  and  the  brain  itself  have  a 
decided  effect.     This  experimental  finding  is  confirmed  by  clinical  observation. 

In  operations  upon  the  tongue,  the  floor  of  the  mouth,  and  the  lips,  if  there 
is  no  loss  of  blood,  there  is  rio  effect  upon  the  blood  pressure.  This  experi- 
mental finding  is  also  confirmed  by  clinical  observation. 

Injury  of  the  mucous  membrane  of  the  nose  had  no  especial  effect  upon 
the  blood  pressure,  but  in  some  cases  there  was  a  temporary  and  partial  inhi- 
bition of  respiration  and  the  heart.  Although  the  mucous  membrane  of  the 
nose  and  the  phar3aix  is  quite  sensitive,  I  have  never  been  able  to  convince 
myself  that  during  operations  incision  or  injury  of  this  tissue  had  any  appreciable 
effect  on  blood  pressure  or  was  adding  to  shock,  but  I  think  that  this  needs 
further  investigation,  and  I  am  inclined  to  the  opinion  that,  in  patients  in 
whom  we  fear  shock  during  operation,  one  should  anaesthetize  this  very  sensi- 
tive mucous  membrane  with  cocaine. 

The  effect  of  injury  of  the  mucous  membrane  of  the  pharynx,  the  soft  palate, 
base  of  the  tong-ue  and  epiglottis  is  one  of  inhibition  on  the  heart  and  respira- 
tion to  a  certain  extent. 

Larynx,  Trachea,  and  Oesophagus. — The  chief  effect  of  irritation  of  the  mucous 
membrane  of  the  larynx,  even  under  anaesthesia,  is  similar  to  that  of  the  epi- 
glottis— a  temporary  arrest  of  respiration.  If  great  force  is  used,  there  may 
be  a  partial  or  complete  inhibition  of  the  heart.  The  larynx,  however,  c^uickly 
becomes  tolerant  to  this  manipulation,  and  the  effects  are  not  noted.  If  the 
superior  laryngeal  nerves  are  divided,  these  manipulations  produce  no  effect 
on  the  respiration  and  heart  action.  The  effect  of  the  application  of  cocaine 
was  similar  to  the  division  of  the  superior  laryngeal  nerve.  This  experimental 
finding  of  Crile  of  the  effect  of  cocaine  used  on  the  mucous  membrane  of  the 
larynx  is  an  important  one  to  remember.  I  am  inclined  to  the  opinion  that 
in  extensive  operations  on  the  larynx,  base  of  the  tongue  and  epiglottis,  and 
sensitive  mucous  membrane  of  nose  and  pharynx  a  preliminary  application 
of  cocaine  would  be  beneficial  ui  that  it  inhibits  the  afferent  impulses  which 
have  an  inhibitory  effect  on  heart  and  respiratory  action. 

Good  {American  Medicine,  August,  1902,  p.  293)  asked  the  question  "are 
not  some  deaths  during  operation  in  regions  supplied  by  the  trifacial  nerve, 
due  to  reflex  inhibition  of  respiration  and  the  heart?" 


472  AMERICAN  PRACTICE  OF  SURGERY. 

Tracheotomy. — When  this  operation  is  clone  under  cocaine,  no  changes  are 
observed  in  blood  pressure.  As  a  rule,  when  the  trachea  is  first  opened,  its 
exposure  to  the  air  produces  coughing,  and  there  may  be  for  a  moment  a  slight 
asphyxia.     This  effect  is  less  if  the  patient  is  under  general  narcosis. 

Asphyxia. — According  to  Crile  asphyxia  produces  a  rise  in  blood  pressure, 
to  be  followed,  after  the  asphyxia  has  passed,  by  a  fall  in  the  pressure  with 
an  increased  rapidity  of  pulse.  Experimental  investigation  on  the  effect  of 
asphyxia  on  the  vasomotor  centres  is  not  complete.  In  practical  surgery 
when  asphyxia  takes  place  during  ether  narcosis  and  the  patient's  general 
condition  is  good,  the  effect  upon  the  patient's  general  condition  as  observed 
by  the  ordinary  methods  is  not  very  marked.  In  weak  patients,  however, 
this  asphyxia  and  cyanosis  become  very  dangerous  factors,  and  the  ana;sthetist 
should  use  every  caution  to  prevent  their  occurrence.  The  asphyxia  or  cyanosis 
produced  by  the  administration  of  nitrous  oxide  has  an  entirely  different  effect 
from  that  produced  by  an  obstruction  to  breathing.  In  the  various  contri- 
butions on  general  ana3sthesia,  when  this  method  has  been  used  to  introduce 
narcosis,  no  bad  effects  upon  the  blood  pressure  have  been  observed.  I  have 
been  \mable  to  find  any  important  contribution  with  observations  on  the  use 
of  nitrous  oxide  in  cases  of  shock. 

Operations  on  the  NecJc. — Lennander  has  demonstrated  that  the  thjToid 
gland  itself  is  insensible.  This  has  been  observed  by  all  surgeons  who  have 
performed  thyroidectomies  under  local  anesthesia.  Cocaine  iirfiltration  is 
only  absolutely  necessary  for  the  skin  incision.  Sometimes  in  the  division  of 
muscles  the  patients  complain  of  pain.  Now  and  then  when  the  thyroid  ves- 
sels are  ligated,  especially  the  veins,  the  patient  may  complain  of  some  discom- 
fort, but  the  remainder  of  the  dissection  is  carried  on  practically  without  pain. 
The  patients  complain  of  great  discomfort,  however,  when  traction  is  made. 
If  the  tumor  is  very  adherent  to  the  trachea,  pain  is  experienced  during  this 
dissection.  It  is  remarkable  how  little  shock  is  observed  in  the  extensive 
operation  for  the  removal  of  larger  goitres,  providing  no  blood  is  lost.  The 
few  blood-pressure  records  confirm  this.  Even  in  patients  with  exophthalmic 
goitre  who  at  the  tmie  of  the  operation  may  have  a  very  rapid  pulse,  one  observes 
no  shock.  Although  the  pulse  is  rapid  in  this  disease,  the  blood  pressure  is 
high,  and  in  the  few  records  has  been  maintained  during  the  thyroidectomy 
under  cocaine  infiltration.  The  chief  danger  is  acute  dilatation  of  the  heart. 
The  insensibility  of  a  thyroidectomy  and  the  absence  of  shock,  if  no  blood  is 
lost,  are  one  of  our  best  examples  illustrating  that  extensive  dissection,  when 
made  through  insensible  tissue,  has  little  or  no  effect  on  the  vasomotor  centres. 
A  contrast  to  this  finding  is  seen  when  one  attempts  to  excise  a  diffuse  lipoma 
of  the  neck,  or  a  mass  of  tuberculous  or  Hodgkin's  glands.  The  dissection 
may  cover  a  smaller  area  than  a  thyroidectomy,  but  this  area  contains  numer- 
ous branches  of  cerebro-spinal  nerves,  difficult  to  expose  and  block  with  the 


SURGICAL  SHOCK.  473 

cocaine  infiltration.     These  patients  sviffer  more  pain  ana  quickly  show  symp- 
toms of  shock. 

E.xtensive  dissections  of  the  neck  are  always  attended  with  a  certain  amount 
of  shock,  even  if  they  are  bloodless.  The  degree  of  shock  is  in  direct  proportion 
to  the  condition  of  the  patient.  In  weak  patients,  therefore,  these  extensive 
dissections  become  elements  of  danger.  The  shock  undoubtedly  is  less  if  all 
manipulations  are  made  with  the  greatest  gentleness,  when  tissues  are  divided 
quickly  with  a  sharp  knife,  and  when  blunt  dissection  is  avoided.  In  oper- 
ations of  this  character,  I  believe  that  the  pneumatic  rubber  suit  of  Crile 
should  be  employed  to  maintain  blood  pressure.  (See  Figs.  140  and  141.)  I 
will  discuss  this  again  imder  Treatment. 

Operations  on  the  Thorax. — These  may  be  divided  into  two  groups.  In 
the  first  the  thoracic  cavity  is  not  opened,  in  the  second  this  cavity  is  opened. 
The  most  common  operation  on  the  chest  belonging  to  the  first  group  is  the 
extensive  dissection  for  carcinoma  of  the  breast.  Crile  in  his  observations 
on  blood  pressure  in  these  cases  noted  only  moderate  changes.  Toward  the 
end  of  the  operation,  especially  during  the  dissection  of  the  axilla,  when  large 
blood-vessels  and  nerves  are  manipulated  and  divided,  a  fall  in  the  blood 
pressure  is  observed.  Crile,  however,  especially  notes  that  when  the  dissection 
is  done  with  a  sharp  knife  and  with  minimum  traction  the  fall  in  blood  press- 
ure is  insignificant.  The  change  in  blood  pressure  is  noted  to  be  marked 
when  the  tissues  are  handled  roughly,  when  the  dissection  is  blunt,  when 
traction  is  made.  These  sentences  of  Crile  sound  the  keynotes  to  the  factors 
which  on  the  one  hand  avoid,  and  on  the  other  increase  shock. 

When  our  patients  are  strong,  the  result  of  the  loss  of  a  certain  amount 
of  blood,  blunt  dissection,  rough  handling,  unnecessar}^  traction  and  ligation 
of  tissues  en  masse,  although  they  would  cause  a  change  of  the  blood  pressure, 
if  such  a  record  were  kept,  do  not  produce  sufficient  depression  to  be  of  much 
clinical  significance.  The  patients  are  a  little  shocked,  convalescence  is  a 
little  prolonged.  However,  when  our  patients  are  very  old  or  very  yoimg, 
or  in  a  weakened  condition  from  any  cause,  these  rough  manipulations  become 
serious  factors,  so  serious  in  some  eases  that  the  operation  cannot  be  completed 
at  all,  or  only  in  a  very  hurried  and  unsatisfactory  manner. 

In  the  very  large  experience  in  the  surgical  clinic  of  the  Johns  Hopkins 
Hospital  with  the  extensive  operation  for  carcinoma  of  the  breast,  I  have 
been  struck  with  two  very  significant  facts — the  absence  of  shock  and  the 
apparent  low  percentage  of  post-ansesthetic  complications.  The  average  anaes- 
thetic time  of  this  operation  has  been  at  least  two  hours,  rarely  less  than  .  n 
hour  and  a  half,  frequently  two  and  a  half  hours,  now  and  then  three,  and 
in  a  few  cases  four  hours.  The  anesthetist  in  this  group  of  cases  seems  to 
be  impressed  with  the  fact  that  it  is  to  be  a  long  operation.  For  this  reason 
he  is  unusually  careful  with  the  anaesthetic,  which  has  always  been  ether.     The 


474  AMERICAN   PRACTICE   OF   SURGERY. 

patients  are  seldom  completely  narcotized.  Although  the  average  age  is  high, 
I  find  that  the  post-operative  pneumonia  is  distinctly  less  frequent  per  hundred 
than  after  operations  for  hernia.  We  have  not  many  blood-pressure  records; 
but,  as  far  as  clinical  observations  can  record,  shock  is  rarely  observed,  and 
has  never  been  serious.  This  apparently  has  been  due  to  the  method  of  dis- 
section established  by  Halsted.  From  the  skin  incision,  throughout  the  oper- 
ation, every  bleeding  point  is  clamped;  the  dissection  is  made  slowly  and  care- 
fully; in  the  axilla  especially,  vessels  and  nerves  are  handled  with  the  greatest 
gentleness,  they  are  isolated  and  ligated  separately;  nerves  are  cut  quickly; 
blmit  dissection  is  never  employed,  except  for  loose  fat  and  cobweb  connective 
tissue  devoid  of  nerves. 

Crile  records  that  resection  of  the  ribs  caused  but  slight  change  of  the  blood 
pressure,  but  opening  the  pleural  cavity  a  marked  change.  When  an  empyema 
is  drained  the  opening  of  the  cavity  and  the  discharge  of  pus  are  attended 
with  a  rapid  fall  of  blood  pressure  and  an  increase  in  the  pulse  rate.  Here 
we  have  another  excellent  and  concrete  example  of  the  elements  which  produce 
shock  and  affect  blood  pressure.  According  to  Lennander  the  parietal  pleura, 
like  the  parietal  peritoneum,  is  extremely  sensitive.  Manipulations  of  either 
are  almost  impossible  under  local  anesthesia.  The  lung  itself  is  insensitive, 
and  the  probabilities  are  that  even  extensive  manipulations  and  cutting  of 
the  lung  would  of  themselves  be  devoid  of  any  effect  on  the  vasomotor  centres. 
It  is  the  opening  of  the  pleural  cavity  that  is  the  chief  factor  of  danger  in  all 
intrathoracic  operations,  chiefly  owing  to  the  change  of  atmospheric  pressure 
with  its  primary  effect  upon  respiration  and  secondaiy  effect  upon  the 
blood-pressure.  The  observations  of  Crile  on  operations  upon  empyema 
are  important  to  recollect.  In  weak  patients  pleural  effusions  should  be 
evacuated  very  slowly.  The  dangerous  effects  of  opening  the  pleural  cavity 
due  to  collapse  of  the  lung  and  its  effect  upon  respiration  and  circulation 
have  limited  this  field  of  surgery.  This  is  not  the  place  to  discuss  Sauer- 
bruch's  experimental  work  or  his  pneumatic  operating  chamber  designed 
to  equalize  atmospheric  pressure  and  eliminate  the  dangers  of  intrathoracic 
operations,  nor  to  consider  Brauer's  method  designed  for  the  same  purpose. 
I  have  discussed  these  contributions  in  the  International  Clinics  for  April, 
1905,  p.  300. 

Extensive  resection  of  ribs,  on  account  of  injur}'  to  the  intercostal  nerves, 
even  if  the  pleural  cavity  is  not  opened,  and  no  blood  is  lost,  is  an  operation 
attended  with  some  shock.  From  a  limited  experience  I  am  inclined  to  the 
view  that  even  if  general  narcosis  is  employed  the  intercostal  nerves  should 
be  blocked  by  a  perineural  injection  of  a  weak  solution  of  cocaine.  The  nerve 
lies  in  the  groove  beneath  the  rib.  In  operations  on  the  thorax  the  sensitive 
tissues  are  chiefly  the  skin,  the  periosteum  of  the  rib,  the  intercostal  nerves, 
and  the  parietal  pleura. 


SURGICAL  SHOCK.  475 

Diaphragm. — According  to  Lennander  the  parietal  peritoneum  and  the 
pleura  on  the  diaphragm  are  unusually  sensitive.  Crile  has  demonstrated 
that  manipulations  of  the  diaphragm,  even  though  slight,  have  a  distinct  effect 
upon  respiration. 

Undoubtedl}'  in  all  intrathoracic  and  abdominal  operations  manipulations 
of  and  traction  on  the  diaphragm  should  be  avoided  if  possible. 

Abdomen. — Lennander's  observations  on  the  sensitiveness  of  the  perito- 
neum and  abdominal  viscera  are  the  most  exhaustive  extant.  The  parietal 
peritoneum  is  extremely  sensitive.  The  visceral  peritoneum  and  the  viscera 
themselves  are  msensitive,  that  is,  all  tissues  innervated  from  the  sympathicus 
and  lower  vagi  are  insensitive  to  touch,  pain,  and  temperature.  The  reverse 
is  true  of  all  tissues  supplied  by  branches  of  the  cerebro-spinal  system.  These 
observations  are  hnportant  not  only  for  the  technique  of  local  ansesthesia,  but 
also  in  operations  upon  the  abdomen,  when  we  wish  to  lessen  or  avoid  shock 
by  reducing  to  a  minimum  sensor}''  impulses  in  cerebro-spinal  nerves.  At 
the  present  time  there  are  no  data,  experimental  or  clinical,  to  indicate  that 
manipulations  of  any  kind  on  these  insensible  viscera  or  tissues  have  any  dele- 
terious effects  on  the  centres  of  circulation  and  respiration.  Handling,  tear- 
ing, and  cutting  the  abdominal  viscera  are  not  harmful  if  done  without  loss  of 
blood.  We  must  recollect,  however,  that  traction  on  these  viscera  irritates 
the  posterior  parietal  peritoneum  and  the  connective  tissues  containing  nerves. 
Theoretically,  therefore,  the  elements  which  produce  shock  in  abdominal 
operations  are  irritation  of  the  parietal  peritoneum  and  traction  on  the  abdom- 
inal viscera.  The  nearer  the  viscera  are  to  the  diaphragm  the  greater  the 
degree  of  this  effect.  Exposure  of  the  abdominal  viscera  to  air  has  a  bad  effect 
chiefly  due  to  loss  of  temperature.  "WTien  viscera  are  taken  out  of  the  abdom- 
inal cavity  traction  and  loss  of  heat  act  together.  These  theoretical  conclu- 
sions based  on  our  knowledge  of  the  sensibility  of  the  abdominal  viscera  are 
borne  out  by  Crile's  experimental  work  and  cluneal  observations.  Manipu- 
lations in  the  pelvis,  or  rather  of  its  viscera,  produce  very  much  less  effect 
than  on  the  higher  organs.  In  no  field  of  surgery  can  its  art  be  better  em- 
ployed in  lessening  the  degree  of  shock  than  in  the  abdomen,  and  it  is  very 
satisfactory  to  find  that  the  conclusions  of  clinical  observers  are  confirmed 
by  scientific  laboratory  experiment.  In  no  other  field  is  the  method  of  anaes- 
thesia of  greater  importance.  In  weak  patients  the  skin  incision  can  be  made 
with  local  infiltration;  the  muscle  opening,  whatever  its  nature,  can  be  per- 
formed without  pain  by  the  proper  intraneural  method  of  Oberst,  so  well 
illustrated  in  Harvey  Cushing's  procedure  for  inguinal  hernia.  General  anes- 
thesia is  now  given  for  the  division  of  the  parietal  peritoneum.  Throughout 
the  remaining  intra-abdominal  operation  the  anaesthesia  deepens  when  any 
manipulation  is  done  which  would  cause,  pain  if  the  patient  were  awake ;  for 
example,    traction,   separation   of    adhesions   from   the   parietal   peritoneum; 


476  AMERICAN   PRACTICE   OF  SURGERY. 

when  abdominal  sponges  are  introduced  or  removed  if  they  come  in  contact 
with  the  parietal  peritoneum.  During  the  operation  per  se  on  the  viscera 
themselves,  the  narcosis  can  be  very  light;  for  example,  throughout  the  entire 
suture  of  a  gastro-enterostomy  practically  no  anaesthetic  need  be  given.  Again, 
when  the  abdominal  wound  is  closed,  the  narcosis  must  be  made  deeper.  In 
long  abdommal  operations  and  in  operations  upon  weak  patients  vigilant 
attention  to  the  most  minute  details  of  narcosis  and  manipulation  of  the  tissues 
is  the  chief  factor  which  insures  success.  In  no  other  operation  is  shock  a 
more  disastrous  complication.  It  may  be  fatal  of  itself.  If  not,  it  so  lowers 
the  resistance  of  the  patient  that  post-operative  comxjlications  are  more  fre- 
quent. The  greater  one's  experience  in  intra-abdominal  surgery  the  more 
is  one  impressed  with  these  facts. 

Spleen. — According  to  Lennander  the  capsule  and  the  parenchyma  of  the 
spleen  are  insensible.  In  operations  under  local  anaesthesia  this  organ  can 
be  handled  with  impunity,  providing  one  does  not  touch  the  parietal  perito- 
neum in  the  neighborhood  or  make  traction  upon  the  spleen.  This  traction 
irritates  the  diaphragm  through  the  ligament,  and  the  posterior  peritoneal 
connective  tissue  with  its  nerves  through  the  splenic  vessels.  Crile  in  his 
experimental  work  on  dogs  found  no  change  in  the  blood  pressure  in  operations 
upon  the  spleen.  Splenectomy,  therefore,  is  of  itself  an  operation  in  which 
shock  need  be  feared  only  if  there  is  hemorrhage  or  necessary  prolonged  and 
vigorous  tension. 

Pancreas. — Crile  records  no  observations  on  manipulations  of  this  organ. 
Lennander  finds  the  parenchyma  of  the  pancreas  insensible.  In  practical 
surgery,  however,  injuries  and  operations  in  the  region  of  the  pancreas  are  fre- 
quently attended  with  an  unusual  degree  of  shock.  This  undoubtedly  is  due 
to  the  numerous  branches  of  spinal  nerves  in  the  peripancreatic  tissue.  In 
rupture  of  the  pancreas  from  contusion  or  wound  and  in  the  so-called  pancreatic 
apoplexy,  in  which  the  pancreas  and  the  peripancreatic  tissue  are  infiltrated 
with  blood  from  the  ruptured  artery,  the  patients  exhibit  a  degree  of  shock 
far  out  of  proportion  to  the  loss  of  blood.  This  general  condition  can  be 
explained  by  the  irritating  effect  of  the  pancreatic  juice  escaping  into  the 
peritoneal  cavity,  which  excites  a  chemical  peritonitis  associated  with  a  hem- 
orrhagic exudate.  Without  much  doubt,  in  addition  to  the  depressing  effect 
of  this  irritant,  there  is  also  a  toxic  element.  The  same  is  true  of  acute  hem- 
orrhagic pancreatitis  in  which  the  general  symptoms — a  combination  of 
shock  and  intoxication — are  far  out  of  proportion  to  the  local  infiltration. 
For  example,  a  similar  hemorrhagic  and  inflammatory  exudate  about  the 
kidnejr  or  the  rectum  is  never  associated  with  such  a  degree  of  general  depres- 
sion. For  this  reason,  in  operations  in  the  region  of  the  pancreas,  injury  of 
this  organ  must  be  avoided,  and  if  incision  or  partial  excision  of  the  pancreas 
is  necessary  the  peritoneal  cavity  must  be  protected  from  the  pancreatic  juice. 


SURGICAL  SHOCK.  477 

Lirer. — The  peritoneal  covering  of  the  liver  and  its  substance,  according 
to  Lennander,  are  insensible.  This  I  have  confirmed  in  local-ana3sthetic  oper- 
ations on  the  abdomen.  An  abscess  of  the  liver,  after  it  has  been  walled  ofi" 
by  gauze,  can  be  opened  secondarily  with  knife  or  Paquelin  cautery  without 
pain.  Practically,  however,  in  operations  in  the  region  of  the  liver,  it  is  diffi- 
cult to  handle  the  organ  without  some  traction  on  the  diaphragm.  This  pro- 
duces pain  if  the  patient  is  not  under  general  narcosis,  and  becomes  a  factor 
in  producing  shock  in  certain  cases.  The  excision,  however,  of  even  large 
pieces  of  liver  with  knife  or  cautery  can  be  performed  without  any  danger 
of  shock  from  this  manipulation.     The  only  element  of  danger  is  hemorrhage. 

Kidney. — The  intimate  capsule  and  parenchyma  of  the  kidney  are  insens- 
ible. Crile  in  his  experiments  found  that  in  cutting,  contusing,  or  crushing 
the  kidney  no  effect  was  observed  upon  the  blood  pressure,  except  when  dur- 
ing these  manipulations  parietal  peritoneum  was  injured.  Nephrectomy  of 
itself  had  very  little  effect  upon  the  blood  pressure.  In  practical  surgery, 
however,  shock  frequently  attends  operations  upon  the  kidney.  The  degree 
of  shock  is  in  a  fairly  direct  proportion  to  the  amoimt  of  manipulation  neces- 
sary to  free  the  kidney.  If  the  diseased  kidney,  tumor,  or  inflammation  is 
very  adherent  to  the  perinephritic  fat  and  connective  tissue  or  the  neighboring 
parietal  peritoneum,  the  manipulations  to  free  the  kidnej^  necessarily  involve 
rough  handling  of  sensitive  tissue.  Considerable  traction  is  required  on  the 
abdominal  wound.  In  these  cases,  even  though  there  be  but  slight  loss  of 
blood,  shock  can  easily  be  recognized  clinically.  Quite  frequently  in  these 
cases  a  considerable  amount  of  oozuig  cannot  be  prevented.  For  these  reasons 
many  of  the  patients  are  quite  shocked.  It  is  in  this  group  of  operations  that 
rapidity  becomes  a  very  important  element  in  preventing  shock.  When  by 
performing  the  operation  slowly  and  carefully  the  surgeon  can  lessen  the  sen- 
sory impulses  which  produce  shock,  time  need  not  be  considered.  However, 
when  he  cannot  avoid  this  rough  handling  of  tissues,  as  in  the  enucleation 
of  an  adherent  diseased  kidney,  shock  is  less  in  direct  proportion  to  the  rapidity 
of  the  operation.  The  anuria  that  may  take  place  as  a  post-operative  compli- 
cation of  kidney  surgery  apparently  cannot  be  based  upon  shock  as  a  factor. 

Testicles. — The  testicle,  epididymis,  and  its  intimate  peritoneal  capsule  are 
insensible  according  to  Lennander.  The  sensory  nerves  are  present  in  the 
skin,  dartos,  and  external  coverings  of  testicle  and  cord.  The  older  views 
that  castration  was  associated  with  an  unusual  degree  of  shock  have  proved 
to  be  fallacious.  According  to  Crile  an  effect  upon  the  blood  pressure  is  only 
observed  when  rough  manipulations  are  made  upon  the  external  coverings 
or  when  one  dissects  a  very  adherent  hernial  or  hydrocele  sac.  Therefore, 
in  operations  for  hernia,  hydrocele,  and  upon  the  testicle  rough  manipula- 
tions should  be  avoided.  In  old  people  with  strangulated  hernia  the  operation 
should  be  always  done  under  cocaine  infiltration.     In  some  cases  no  attempt 


478  AMERICAN   PRACTICE   OF   SURGERY. 

should  be  made  to  excise  the  sac,  because,  on  account  of  its  size  or  adhesions, 
these  manipulations  become  elements  of  danger  in  increasing  shock.  When 
the  sac  is  not  adherent  and  can  be  enucleated  without  difficulty,  there  is  no 
increased  danger  in  its  removal. 

Spinal  Column. — Crile  demonstrated  that  in  operations  of  laminectomy  no 
change  was  observed  in  the  blood  pressure  until  the  membranes  of  the  cord 
were  exposed.  Contact,  however,  with  sensory  nerve  roots  showed  the  most 
marked  change.  In  my  limited  experience  with  laminectomy  I  have  been 
surprised  at  the  absence  of  much  shock.  Undoubtedly  the  skin,  muscles,  and 
deeper  tissues,  if  one  confines  the  incision  to  the  middle  line,  contain'  very 
few  sensory  nerves.  Crile  demonstrated  this  in  laminectomy  under  cocaine 
infiltration.  Nor  did  his  patient  experience  pain  when  the  spinous  processes 
and  lamina  were  divided. 

Extremities. — In  amputations  the  chief  factors  which  produce  shock  are 
the  divisions  of  the  skin  and  nerves.  This  can  be  prevented  by  cocaine  in- 
jections. That  tearing  of  the  skin  and  of  the  nerves  are  definite  factors  in  pro- 
ducing shock  is  confirmed  by  observations  in  accident  surgery.  All  patients  with 
lacerated,  contused,  or  crushed  wounds  of  the  extremities  are  shocked  in  direct 
proportion  to  the  injury  of  the  skin  and  larger  nerve  trunks.  The  shock  may 
be  extreme  without  the  loss  of  blood.  There  is  no  evidence  to  indicate  that 
the  crushing  or  fracture  of  the  bone  is  of  itself  a  factor.  For  example,  in  exten- 
sive comminuted  fractures  without  complicating  injuries  of  the  soft  parts  there 
is  no  shock.  The  treatment  of  patients  with  extensive  injuries  of  the  extrem- 
ities and  shock  is  one  of  the  important  problems  of  traumatic  surgery,  and 
will  be  discussed  later. 

Duration  of  the  Operation. — From  the  preceding  discussion  one  can  easily 
understand  that  the  time  of  the  operation  becomes  a  distinct  element  in  shock 
only  when  during  this  time  manipulations  are  made  which  produce  sensory 
impulses.  As  stated  before,  when  discussing  kidney  operations,  it  is  better  to 
prolong  the  operation,  if  by  this  these  sensory  impulses  can  be  avoided.  When, 
however,  the  manipulations  necessary  for  the  operative  procedure  are  factors 
which,  we  know,  will  produce  shock,  the  time  of  the  operation  should  be  short- 
ened as  much  as  possible.  Irrespective  of  the  manipulations,  there  are  two 
other  factors  which  produce  shock,  which  must  be  borne  in  mind,  as  they  are 
increased  by  the  duration  of  the  operation:  first,  the  general  anassthetic, 
second  the  lowering  of  the  temperature  by  exposure  of  large  areas  of  fresh 
tissues  to  the  air.  In  long  operations  the  quantity  of  the  anaesthetic  can  be 
greatly  reduced  by  the  so-called  method  of  interrupted  narcosis,  which  I  dis- 
cussed under  operations  upon  the  abdomen.  The  tissues  can  be  protected 
by  moist  warm  gauze.  Within  certain  limits  of  time,  I  do  not  believe  that 
the  general  anassthetic  or  the  exposure  of  tissues  to  air  is  as  important  a  factor 
in  producing  shock  as  the  rough  handling  of,  tissue.     It  frequently,  then,  be- 


SURGICAL  SHOCK.  479 

comes  a  choice  of  evils,  and  personally  I  would  prefer  a  little  longer  operation 
for  a  gentle  dissection,  bloodlessly,  to  a  shorter  operation  with  more  hemorrhage 
and  rough  handling. 

Anaesthesia:  The  Relation  of  Anaesthesia  to  Shock.— Continuous  anesthesia 
alone  will  kill  animals.  Chloroform  is  a  more  potent  factor  than  ether.  Crile 
in  all  of  his  experimental  work  on  animals  considered  that  the  general  anaes- 
thetic was  always  a  factor.  Blauel  (Beitrage  zur  klin.  Chir.,  1901,  vol.  xxx., 
p.  271)  was  one  of  the  first  to  contribute  extensive  observations  on  blood  press- 
ure during  ether  and  chloroform  narcosis.  When  other  factors  are  eliminated 
the  arterial  tension  during  ether  narcosis  is  well  maintained  and  usually  slightly 
increased,  while  in  chloroform  narcosis  there  were  observed  great  fluctuations 
and,  as  a  rule,  a  lower  blood  pressure.  Chloroform,  therefore,  should  never 
be  given  in  shock  or  in  any  cases  in  which  the  lowering  of  the  vasomotor 
tone  would  be  dangerous  to  the  patient.  The  most  recent  communication 
Hjii  this  subject  is  by  Mueller  (Archiv  /.  klin.  Chir.,  1905,  vtal.  Ixxv.,  p.  896,  and 
vol.  Ixxvii.,  p.  420).  Mueller's  observations  are  concerned  chiefly  with  mixed 
narcosis.  He  has  demonstrated  to  his  own  satisfaction  that  oxygen  is  a  very 
important,  perhaps  essential  gas  to  combine  with  every  anesthetic.  In  an 
oxygen-chloroform  narcosis  the  depression  and  fluctuation  of  the  blood  pressure 
are  less  marked  than  with  simple  chloroform.  The  oxygen-ether  narcosis 
gives  better  results  as  regards  blood  pressure  than  the  simple  ether  or  oxygen- 
chloroform.  In  some  cases  the  best  results  were  obtained  with  a  mixed  oxygen- 
ether-chloroform  narcosis  given  with  a  special  apparatus.  I  have  had  no 
personal  experience  with  these  mixed  general  narcoses,  nor  with  the  various 
apparatus  used  for  their  introduction.  In  my  own  experience  I  have  so  far 
been  satisfied  with  ether  given  by  the  drop  method  on  an  ordinary  chloroform 
mask.  This  has  proved  the  most  satisfactory  anesthetic  in  cases  of  shock 
or  in  weak  patients  for  whom  a  general  narcosis  was  absolutely  necessary. 
A  patient  in  a  condition  of  shock  requires  very  little  anesthetic.  One 
seldom,  if  ever,  observes  the  cyanosis  and  asphyxia  which  now  and  then  are 
a  complication  in  robust  individuals.  I  always  combine,  if  possible,  a 
local  cocaine  infiltration  with  the  general  narcosis  in  cases  of  shock  or  in 
patients  in  whom  I  anticipate  shock.  Further  investigation  undoubtedly 
should  be  made  to  demonstrate  if  Mueller's  conclusions  are  correct.  If  they 
are,  oxygen  and  its  combination  with  ether,  or  ether  and  chloroform,  should 
be  employed. 

Local  Ana'sthesia. — There  is  no  doubt  that  if  the  operation  can  be  performed 
painlessly  under  local  anesthesia  there  is  less  shock  than  if  a  general  narcotic 
is  employed.  But,  it  is  very  important  to  remember  that  the  danger  of  a 
general  anesthetic  is  less  than  the  prolonged,  'painful  attempt  under  local 
anesthesia.  In  the  early  years  of  local  anesthesia  many  of  its  advocates 
were  so  enthusiastic  that  they  did  not  seem  to  appreciate  that  some  manipu- 


480  AMERICAN   PRACTICE   OF   SURGERY. 

lations  were  painful.  Strong  individuals  can  stand  it,  and  there  is  no  question 
that  for  these  patients  the  dangers  of  pain  during  the  operation  are  less  than 
the  dangers  of  a  general  ansesthetic.  But  this  is  not  true  in  patients  sviffering 
from  shock,  or  in  weak,  young,  or  very  old  individuals.  In  these  latter  cases 
one  should  attempt  as  much  as  possible  with  local  ansesthesia,  but  for  painful 
manipulations  general  narcosis  is  indicated.  For  the  proper  procedure  in 
these  cases  one  will  find  the  observations  of  Lennander  on  the  sensitiveness 
of  tissues  and  organs  of  the  greatest  value. 

Spinal  Anesthesia. — With  this  method  I  have  had  no  personal  experience, 
but  since  its  introduction  I  have  interested  myself  thoroughly  in  its  literature. 
There  are  no  observations  to  indicate  that  it  produces  shock.  Its  dangers 
are  due  to  the  toxic  effects  of  the  cocaine  introduced  subdurally.  A  patient 
intoxicated  with  cocaine  undoubtedly  has  a  lower  resistance.  Blood-pressure 
records  in  spinal  anaisthesia,  if  niade,  have  not  been  published  to  any  extent, 
until  the  communication  from  Bier's  clinic  by  Mori  {Deutsche  Zeitschrift  /.  Chir., 
1904,  vol.  Ixxiv.,  p.  173).  In  these  observations  the  spinal  ansesthesia  was  pro- 
duced by  the  new  method  of  Bier  in  which  adrenalin  is  employed  with  cocaine. 
No  blood  pressure  observations  were  made  m  those  cases  which  were  anaesthe- 
tized with  cocaine  alone.  Mori  found  very  little  in  the  literature  on  the  effect 
of  cocaine  injected  intraneurally.  His  observations  demonstrate  that  the 
blood  pressure  in  spinal  anaesthesia  produced  by  adrenalin  and  cocaine  is  not 
as  well  maintained  as  that  observed  after  a  general  ether  narcosis,  but  is  very 
much  better  than  that  observed  after  chloroform  narcosis.  There  is  no  evi- 
dence from  this  observation  alone  that  spinal  anaesthesia  is  a  better  method 
than  ether  narcosis  for  shock.  The  experimental  work  of  Schieffer,  also  from 
Bier's  clinic  {Deutsche  Zeitschr.  f.  Chir.,  1905,  vol.  Ixxvi.,  p.  581),  however, 
is  very  suggestive.  He  demonstrated  that  if  animals  are  shot  from  a  distance 
of  from  30  to  40  metres  they  fall  and  do  not  rise ;  that  is,  the  immediate  effect 
of  the  contact  of  the  shot  is  out  of  proportion  to  the  actual  injury.  When, 
however,  these  dogs  are  first  anaesthetized  by  spinal  anaesthesia  the  immediate 
shock  is  either  not  present  at  all  or  is  very  much  reduced.  Klapp  believes 
that  spinal  anaesthesia  blocks  the  afferent  sensory  impulses  in  very  much  the 
same  manner  as  they  are  blocked  by  an  injection  of  a  nerve  trunk.  It  will 
require  further  investigation  to  determine  whether  these  findings  can  be  utilized 
in  practical  surgery.  It  is  suggestive,  however,  that  for  extensive  injuries  of 
the  lower  extremities  it  might  be  a  good  plan  immediately  to  block  further  sen- 
sory impulses  by  an  intraneural  injection  and  then  proceed  with  the  necessary 
amputation. 

Scopolamine-Morphine  Ano'sthesia. — At  the  present  time  I  have  been  unable 
to  find  any  blood-pressure  records  made  when  this  method  of  anaesthesia  has 
been  employed,  or  to  learn  whether  it  has  any  advantage  over  cei'ebral  or  spinal 
narcoses  in  shock. 


SURGICAL  SHOCK.  481 

Hemorrhage. — According  to  Crile  loss  of  blood  always  predisposes  to  shock, 
and  when  it  is  considerable,  even  if  it  cause  but  little  depression  in  the  blood 
pressure,  the  animal  does  not  withstand  a  rather  severe  or  protracted  operation. 
Hemorrhage  from  venous  trunks  caused  the  most  profound  impression.  In 
practical  surgery  hemorrhage  is  a  very  important  element  in  shock.  In  my 
own  experience  I  never  feel  the  same  anxiety  when  patients  exliibit  symptoms 
of  shock  if  there  has  been  no  loss  of  blood.  If,  however,  there  has  been  con- 
siderable loss  of  blood,  the  appearance  of  sj^mptoms  of  shock  should  be 
regarded  as  an  indication  to  cease  further  operative  manipulations  at  once, 
if  possible.  For  example,  in  cases  of  osteomyelitis  in  children,  situated  in 
the  upper  portion  of  the  femur,  where  an  Esmarch  cannot  be  used,  the  opera- 
tion in  some  cases  has  had  to  be  performed  in  two  or  more  sittings.  The 
bleeding  from  the  involucrum  is  always  considerable  and,  without  an  Esmarch, 
cannot  be  checked  during  the  necessary  chiselling  to  explore  the  infected 
medullary  cavity.  I  have  records  of  at  least  five  cases  in  which  the  condi- 
tion of  the  patient  was  sufficiently  threatening  to  indicate  immediate  packing 
of  the  wound  and  a  postponement  of  further  operation  for  some  days.  In 
these  cases  the  operation  has  been  completed  in  two  or  more  sittings,  with 
recovery  of  the  patient. 

Clinical  Observations  on  the  Various  Factors  which  Produce  Shock.— In  the 
previous  discussion  on  the  experimental  work  it  was  impossible  not  to  discuss 
from  time  to  time  the  confirming  clinical  observations.  Unfortunately,  at 
the  present  time  I  cannot  obtain  a  sufficient  number  of  blood-pressure  observa- 
tions taken  before,  during,  and  after  various  operations  to  compile  conclusions 
of  practical  value.  At  the  present  time,  few,  if  any,  surgeons  have  had  suf- 
ficient experience  with  blood-pressure  records  to  depend  upon  them  for  an 
estimation  of  the  patient's  condition  during  the  operation.  In  the  majority 
of  instances  a  surgeon  of  experience  can  judge  pretty  accurately  the  general 
condition  of  the  patient,  and,  as  a  rule,  seldom  loses  a  patient  from  shock. 
This  estimation  is  not  based  upon  a  single  factor.  His  careful  study  of  the 
case  before  operation  gives  him  an  esthnate  of  the  strength  of  the  patient ;  his 
knowledge  of  the  sensibility  of  the  tissues  to  be  manipulated  at  the  necessary 
operation  gives  him  a  fair  idea  of  the  amount  of  shock  he  will  produce.  As 
the  operation  proceeds,  the  character  of  the  respiration  and  pulse  and  the 
color  of  the  skin  and  lips  indicate  how  the  patient  is  standing  the  operation. 
It  is  not  so  much  the  rapidity  of  the  pulse  or  respiration,  as  the  compara- 
tive frequency  of  the  pulse  and  respiration,  during  the  operation,  that  indi- 
cates how  the  patient  is  withstanding  the  ordeal. 

In  the  majority  of  cases  subjected  to  operation  the  general  condition  of 
the  patient  is  such  that,  if  the  anaesthesia  is  properly  given  and  the  operation 
carefully  performed  without  the  loss  of  blood,  the  danger  of  shock  is  so  insig- 
nificant that  it  need  not  be  considered.     In  these  cases  we  do  not  need  an 

VOL.  I.— 31 


482  -\:\1ERICAX  PRACTICE   OF   SURGERY. 

instrument  of  precision  to  record  the  blood-pressure,  although  records  in  these 
cases  should  be  made  for  their  value  in  a  comparative  stud}'. 

In  a  smaller  group  of  cases  the  significance  of  shock  is  of  the  greatest  impor- 
tance.    Various  factors  come  into  consideration: 

Anotmia. — Patients  with  secondarj^  anaemia,  especiall}^  if  the  haemoglobin 
is  low,  are  not  good  subjects  for  operation.  AR  the  factors  which  produce 
shock  apparently  act  in  these  cases  with  greater  severity — the  general  anaes- 
thetic, slight  loss  of  blood,  all  operati^-e  manipulations  are  never  borne  as 
well  as  in  individuals  with  a  normal  blood  comit.  This  subject  I  have  discussed 
with  the  literature  in  Progressive  Medicine  for  December,  1901,  p.  207. 

It  is,  therefore,  verj^  important  for  the  surgeon  to  insist  upon  a  complete 
blood  coimt  m  all  those  cases  in  which  there  is  clinical  eA'idence  of  anaemia. 
Theoretically  a  blood  comit  should  be  made  in  everj-  instance.  I  believe  it  is 
more  important  than  an  examination  of  the  ui'me.     In  practice  it  is  not  done. 

Diabetes. — There  is  considerable  literatm'e  on  the  results  of  operation  in 
patients  suffering  with  diabetes.  I  am  mclined  to  thmk  that  the  dangers  are 
somewhat  overestimated.  Undoubtedly  the  diabetic  patient  has  a  lowered 
resistance,  and  it  is  sometunes  difficult  to  estimate  the  advent  of  diabetic  coma. 
Undoubtedh',  in  cases  suffering  with  diabetes,  one  would  imdertake  an  opera- 
tion onlj'  when  absolutely  necessarj-.  In  my  own  experience  three  cases  of 
appendicular  abscess  suffering  with  diabetes  took  the  anaesthetic  well  and 
exhibited  no  sjonptoms  of  shock  after  the  short  operation  necessary  to  ilrain 
the  abscess.  In  a  nximber  of  patients  with  gangrene  of  the  extremities  due 
to  arterio-sclerosis  in  which  there  was  also  glycosuria  I  obser\'ed  that  the  anaes- 
thetic was  well  taken  and  there  was  no  extreme  degi'ee  of  shock  after  the  neces- 
sary' amputation.  One,  however,  approaches  an  operation  on  a  diabetic  patient 
with  great  caution  and  uses  every  means  to  lessen  the  quantity  of  the  anaes- 
thetic administered  and  shorten  the  operation. 

Nephritis. — Operations  are  seldom  performed  when  the  clinical  picture  of 
this  disease  is  established.  In  looking  over  the  records  I  find  a  nmnber  of 
cases  in  which  albumin  and  casts  were  present  in  the  lu-rne  without  any  other 
definite  SATiiptoms  of  nephritis.  As  a  rule,  local  anaesthesia  has  been  em]3loyed 
in  such  cases  whenever  possible.  In  studjong  the  histories  of  these  cases  and  a 
few  with  definite  nephritis,  as  well  as  the  literature  on  decapsulation  of  the  kirlney 
for  different  forms  of  acute  and  chronic  Bright's  disease,  one  is  impressed  ■nith  the 
fact  that  these  patients  take  the  anaesthetic  well  and  are  not  more  shocked 
than  patients  without  these  kidney  lesions.  The  danger  apparently  is  not  from 
shock,  but  from  the  effect  of  the  anaesthetic  and  operative  manipulations  on 
kidnej'  function,  a  subject  to  be  discussed  elsewhere  in  this  system. 

Therefore,  in  this  group  of  cases  the  same  care  should  be  emploj'ed  as 
that  used  in  patients  sufi'eruig  from  shock  or  in  whom  we  fear  shock,  because 
these  preventive  measures  are  important  to  lessen  both  dangers. 


SURGICAL  SHOCK.  483 

Alcoholism. — My  experience  in  surgery  on  this  class  of  patients  is  limited, 
nor  am  I  familiar  with  this  literature.  One  is  chiefly  impressed  that  this  class 
take  the  general  anajsthetic  badly.  The  dangers  of  general  narcosis  are  always 
greater,  and  therefore,  as  narcosis  is  always  a  factor  in  shock,  it  is  exaggerated 
in  patients  addicted  to  the  excessive  use  of  alcohol.  There  are  sufficient  blood- 
pressure  records  to  demonstrate  that  alcohol  is  of  no  value  as  a  stimulant  in 
shock.  In  large  doses  it  is  a  depressant,  and  for  this  reason,  in  accident  surgery, 
if  the  patient  comes  to  the  surgical  clinic,  as  they  frequently  do,  overdosed 
with  whiskey  given  them  as  a  "first-aid"  measure  by  the  ignorant,  this  intox- 
icated state  must  be  borne  in  mind  and  considered  in  the  treatment.  As  far 
as  my  own  experience  goes,  acute  and  chronic  alcoholism  must  be  regarded 
pathologic  conditions  in  which  the  patient  is  less  resistant  to  all  the  factors 
which  produce  shock.     Alcohol  is  contraindicated  in  the  treatment  of  shock. 

General  Infection. — It  has  been  my  personal  experience  that  patients  suf- 
fering with  general  infection  react  more  quickly  to  all  the  factors  that  produce 
shock,  and  this  must  be  borne  in  mind  in  all  operations.  A  high  temperature 
and  toxins,  whatever  their  character,  apparently  after  a  time  affect  the  centres 
in  very  much  the  same  manner  as  do  the  sensory  impulses  which  produce 
shock.  Whether  these  are  of  an  inhibitory  or  of  a  depressant  character  has 
not  been  demonstrated.  Every  one  is  familiar  with  the  rapidity  with  which 
shock  manifests  itself  when  patients  are  operated  upon  for  general  peritonitis, 
and  how  much  more  careful  one  must  be  in  performing  the  necessary  abdominal 
manipulations.  In  these  cases  the  patient  may  sviddenly  become  almost 
pulseless  when  the  intestines  are  removed  from  the  peritoneal  cavity.  On 
the  other  hand,  in  the  normal  individual  one  may  keep  the  intestines  out  of 
the  abdominal  cavity  under  tension  for  a  relatively  long  time  before  symp- 
toms of  shock  manifest  themselves.  Amputations  for  infected  compound 
fractures  or  for  any  infection  of  the  extremities  are  associated  with  a  rela- 
tively greater  degree  of  shock  than  amputations  for  tumors.  It  is  important, 
therefore,  to  bear  in  mind  that  operations  upon  patients  suffering  with  general 
infection  must  be  conducted  on  the  supposition  that  shock  is  a  very  dangerous 
factor. 

Local  Infections. — According  to  Lennander,  in  all  tissues  and  organs  sup- 
plied by  sensory  nerves  from  the  cerebro-spinal  system  the  sensibility  is  increased 
by  an  inflammatory  lesion.  Practically,  this  knowledge  is  not  of  very  great 
importance  in  relation  to  shock.  It  is  better,  however,  to  handle  these  inflamed 
sensitive  tissues  more  gently.  On  the  other  hand,  all  tissues  and  organs  not 
supplied  by  these  sensory  nerves,  but  by  the  sympathicus  and  lower  vagus, 
are  no  more  sensitive  when  they  are  the  seat  of  disease,  and  for  this  reason  they 
can  be  handled  with  just  as  much  impunity. 

In  local  anesthesia  it  has  been  demonstrated  that  inflammation  of  sensitive 
tissues  increases  their  sensitiveness  to  such  a  degree  that,  in  the  majority  of 


484  AMERICAN  PRACTICE  OF  SURGERY. 

instances,  unless  the  nerve  can  be  blocked  above  the  area  of  inflammation, 
an  operation  cannot  be  performed  under  this  method  of  anesthesia. 

Starvation. — I  use  this  term  to  define  a  condition  of  loss  of  weight  and 
strength  attributable  to  defective  nutrition,  no  matter  what  its  cause.  We  observe 
the  extreme  degrees  more  especially  m  strictures  of  the  oesophagus,  carcinoma 
of  the  stomach,  pyloric  stenosis,  and  chronic  obstruction  of  the  small  and 
large  intestines.  Undoubtedly,  in  the  cases  of  pyloric  stenosis  and  chronic 
obstruction  of  the  intestine  lower  down  there  is  another  factor,  that  of  auto- 
intoxication. These  patients  are  all  bad  subjects  for  operation.  They  ciuickly 
react  with  shock  to  every  factor — anaesthesia,  duration  of  operation,  iiem- 
orrhage,  manipulation  of  sensitive  tissues  and  organs.  In  this  group,  perhaps 
more  than  any  other,  the  surgeon  must  use  all  the  means  at  his  command  to 
prevent  a  fatal  condition  of  shock. 

Auto-intoxication. — This  term  is  used  to  define  a  condition  of  general  infec- 
tion due  to  the  absorption  of  toxins  from  the  alimentary  tract.  Its  acute 
form  is  observed  in  all  cases  of  acute  intestinal  obstruction;  the  chronic 
form  in  all  cases  of  pyloric  stenosis  and  chronic  intestinal  obstruction.  Patients 
suffering  from  this  toxsemia  are  bad  subjects  for  operative  intervention. 

Jaundice. — The  chief  danger  of  surgical  intervention  on  patients  suffering 
with  obstructive  jaimdice  is  that  of  secondary  hemorrhage.  In  looking  over 
the  records  of  operative  intervention  upon  patients  suffering  with  jatindice 
due  to  stone  in  the  common  duct  I  have  been  unable  to  fkid  any  positive  evidence 
that  they  are  bad  subjects  for  anaesthesia  and  the  necessary  operative  manip- 
ulation because  of  the  jaundice  alone.  Those  cases  in  which  there  are,  in  addi- 
tion, marked  anaemia  and  loss  of  weight,  exlribit  greater  reaction  to  the  operation 
than  those  cases  m  which  the  jaundice  is  even  more  intense,  but  in  which  there 
is  no  anffimia  or  loss  of  weight.  It  is  the  duration  of  the  jaundice,  and  not 
its  intensity,  that  chiefly  affects  the  general  condition  of  the  patient  and  lowers 
his  resistance.  The  operative  manipulations  necessary  to  expose  the  common 
duct,  especially  if  there  are  adhesions,  are  of  a  character  that  undoubtedly, 
if  prolonged,  or  performed  upon  patients  with  lowered  resistance,  produce 
shock.  This  should  be  borne  in  mind. 

Acute  Hemorrhagic  Pancreatitis. — In  the  clinical  picture  of  the  early  hours 
of  this  disease  shock  is  a  prominent  feature.  In  the  discussion  of  the  operative 
treatment  of  this  lesion  there  has  been  much  difference  of  opinion  as  to  whether 
intervention  is  justifiable  on  account  of  this  condition  of  depression  verging  on 
collapse.  In  these  cases,  if  an  operation  is  decided  upon,  every  effort  should  be 
made  to  shorten  the  anicsthotic  time  and  to  limit  the  abdominal  manipulations. 

Shock  Associated  with  Injury. — In  accident  surgery  many  patients  are 
admitted  to  the  clinic  in  a  condition  of  shock  the  degree  of  which  varies.  When 
an  operation  is  demanded  on  account  of  the  nature  of  the  injury,  the  surgeon 
must  not  only  recognize  that  shock  is  present,  but  must  estimate  its  degree. 


SURGICAL  SHOCK.  485 

Shock  and  Hemorrhage. — In  accident  surgery  the  first  important  factor 
to  be  estimated  is  whether  the  shock  is  due  to  hemorrhage  or  is  simply  the  result 
of  injury.  This  differential  diagnosis  is  of  chief  importance  when  the  injury 
is  subcutaneous,  in  the  chest  or  abdomen,  or  about  the  great  blood-vessels  in 
the  axilla,  groin,  or  limbs.  Hemorrhage  must  be  checked  by  immediate  oper- 
ation, no  matter  what  the  degree  of  shock.  This  differential  diagnosis,  when 
the  possible  area  of  hemorrhage  is  concealed,  is  frequently  difficult.  When 
the  injury  is  in  the  region  of  the  axilla,  groin,  or  the  limbs  the  presence  of  a 
rapidly  increasing  swelling  is  a  definite  indication  of  vessel  injury  and  the 
formation  of  a  hsematoma.  A  decision  in  regard  to  operative  intervention 
in  such  cases  is  frequently  very  difficult.  Experience  has  demonstrated  that 
in  a  certain  number  of  cases  the  tension  of  the  surrounding  tissues  limits  after 
a  time  the  size  of  the  ha3matoma,  that  thrombosis  takes  place  in  the  ruptured 
vessel,  and  accomplishes  a  stoppage  of  the  hemorrhage  which  for  the  time 
has  threatened  life.  In  these  cases  the  operative  manipulation  is  usually  of 
sufficient  magnitude  to  contraindicate  its  immediate  performance.  For  this 
reason  it  should  never  be  performed  unless  the  indications  are  that  thrombosis 
is  not  taking  place  in  time  to  save  the  patient  from  death  from  loss  of  blood. 
The  degree  of  shock  in  these  cases  is  the  best  sign  of  an  indication  for  operation. 

The  differential  diagnosis  between  shock  from  abdominal  contusion  with- 
out hemorrhage,  and  that  with  hemorrhage  from  rupture  of  the  viscera,  is  a  very 
difficult  one.  In  the  former,  operation  is  contraindicated;  in  the  latter,  inune- 
diate  laparotomy  is  imperative. 

Experience  has  demonstrated  that  ruptures  of  the  liver  and  spleen  and 
large  vessels  of  the  abdomen  have  not  the  same  tendency  to  spontaneous  cessa- 
tion by  thrombosis.  Here  the  blood  escapes  into  the  free  peritoneal  cavity. 
The  conditions  favorable  to  thrombosis  which  are  present  in  the  rupture  of  the 
large  vessels  of  the  extremities  are  absent  in  the  abdomen. 

As  a  rule,  an  injury  of  sufficient  force  to  produce  a  rupture  of  the  abdominal 
viscera  would  of  itself  cause  shock.  In  my  own  experience  the  degree  of  shock 
is  never  as  great  as  m  those  cases  in  which  there  is,  in  addition,  hemorrhage. 
For  this  reason  an  accumulated  experience  enables  one  to  make  the  proper 
diagnosis  in  the  majority  of  cases.  Movable  dulness  in  the  flanks  is  path- 
ognomonic of  hemorrhage;  it  is  not  always  present.  A  blood  count  theoret- 
ically should  be  of  value,  but  experience  has  demonstrated  that,  as  a  rule,  the 
blood-changes  do  not  take  place  quickly  enough  after  the  hemorrhage  to  be 
of  aid  in  the  necessary  immediate  diagnosis.  The  leucocytosis  of  hemorrhage 
does  not  appear  until  some  hours  after  the  accident.  The  aid  of  a  blood-coimt 
imfortunately  cannot  be  depended  upon  in  these  cases.  In  the  literatine 
the  recoveries  after  immediate  laparotomy  for  rupture  of  the  spleen,  liver,  and 
pancreas  have  been  due  to  an  immediate  intervention  based  upon  the  history 
of  the  injury  and  the  clinical  pictiire  of  shock.     Now  and  then  an  abdomen  is 


486  AilERICAN  PRACTICE  OF  SURGERY. 

opened  unnecessarily.  But  if  the  exploratory  exposure  of  the  abdominal  cavity 
is  performed  under  local  anaesthesia,  there  should  be  no  mortality  in  the  cases 
with  negative  findings.  Unfortunately,  I  am  unable  to  present  any  blood- 
pressure  studies  in  these  cases  to  demonstrate  that  measurements  are  of  diag- 
nostic value.     I  am  inclined  to  think  that  they  would  be. 

In  rupture  of  the  kidney  the  problem  is  perhaps  a  more  difficult  one,  be- 
cause experience  has  demonstrated  that  in  quite  a  number  of  cases  the  hemor- 
rhage ceases  spontaneously.  Yet,  in  other  cases,  life  has  apparently  been 
saved  by  immediate  incision  and  packing,  or,  in  a  few  cases,  by  nephrectomy  with 
ligation  of  the  renal  vessels.  In  this  group  the  indications  for  operation  are 
based  upon  the  degree  of  shock,  the  size  and  increasing  development  of  the 
perii'enal  hgematoma. 

In  contusions  of  the  chest  with  hemorrhage  from  the  mtercostal  vessels 
or  ruptured  lungs  the  problem  of  operative  intervention  is  a  very  difficult  one 
to  solve.  My  own  experience  has  been  limited,  and  the  literature  is  somewhat 
scanty.  The  same  principles  apply  as  those  discussed  under  rupture  of  the 
kidney,  or  a  subcutaneous  injury  of  a  large  blood-vessel  of  a  limb.  In  the 
intrathoracic  hemorrhage  a  certain  number  of  patients  recover  without  operative 
intervention.  In  others  the  hemorrhage  must  be  checked  by  exposure  of  the 
bleeding  vessels.  Here  again  the  degree  of  shock  is  of  aid,  and  the  increasing 
area  of  thoracic  dulness  indicates  the  amount  of  hemorrhage.  The  results  of 
intervention  in  cases  of  rupture  of  the  intercostal  vessels  have  been  good;  on 
the  other  hand,  the  results  obtained  in  cases  of  rupture  of  the  lung  are  not  very 
encouraging. 

All  of  these  cases  should  be  watched  very  carefully,  and  when  the  condition 
of  shock  gradually  grows  worse  and  the  physical  signs  indicate  an  increase 
of  the  ha-matoma  there  should  be  no  further  delay.  This  group  of  cases  de- 
monstrates how  important  it  is  for  surgeons  to  study  very  critically  shock  in 
all  of  its  clinical  manifestations,  and  how  much  we  are  in  need  of  blood-pressure 
and  blood-count  records. 

Amputation  During  Shock. — This  subject  has  been  one  of  discussion  from 
the  beginning  of  surgery.  In  all  injuries  of  the  limbs  associated  with  an  extreme 
degree  of  shock,  and  in  which  the  nature  of  the  injury  demands  either  ampu- 
tation or  some  other  operative  manipulation,  the  question  at  once  arises 
whether  the  best  results  are  obtained  by  immediate  action  or  whether  the 
patient's  chances  of  recovery  are  better  if  the  operation  is  delayed.  Experience 
has  demonstrated  that  there  is  no  fixed  rule.  In  a  certain  number  immediate 
operation  must  be  performed,  in  others  it  is  better  to  delay.  The  duration  of 
the  time  of  postponement  varies.  Hemorrhage  is  always  an  indication  for 
immediate  intervention  and  must  be  checked,  even  though  it  demand  an 
extensive  operation.  The  danger  of  further  loss  of  blood  is  much  gi-eater 
than  the  danger  of  an  operation  m  a  condition  of  shock.     If  hemorrhage  has 


SURGICAL  SHOCK.  487 

ceased,  operation  may  be  indicated,  because  the  pain  from  the  nmtilated  hmb 
is  sufficient  to  be  considered  as  a  factor  which  will  increase  shock.  When 
these  two  factors  are  absent,  it  is  better  to  delay  in  order  that  the  patient  may 
have  the  opportunity  to  recover  as  much  as  possible.  The  operation,  how- 
ever, must  not  be  postponed  too  long,  because  after  a  time  the  element  of 
infection  becomes  an  important  factor. 

Wainwright,  of  Scranton,  Pennsylvania,  has  had  a  large  experience  in  trau- 
matic surgery  and  has  contributed  to  the  question  under  discussion  ("Clinical 
Studies  in  Blood-Pressure  and  Shock  in  Traumatic  Surgery,"  Medical  News, 
New  York,  March  25,   1905). 

He  writes:  "To  remove  the  nerve  impulses  after  trauma,  an  immediate 
repair  of  the  injury,  if  at  all  feasible,  is  very  important.  For  this  reason  our 
own  view  is  strongly  in  favor  of  primary  amputations  in  limbs  hopelessly 
mangled.  Leaving  a  mangled,  oozing  limb  with  crushed  and  exposed  nerves, 
in  the  hope  that  delay  will  give  a  more  favorable  opportunity  for  intervention, 
will,  in  many  cases,  by  allowing  the  cause  continually  to  act,  only  drive  the 
patient  into  a  condition  beyond  all  hope.  A  well-covered  stimip  with  oozmg 
checked,  on  the  other  hand,  will  give  a  chance  to  a  patient  in  whom  the  cause 
of  shock  is  stopped  and  to  whom  the  administration  of  therapeutic  measures 
will  not  be  like  pouring  water  through  a  sieve." 

There  are  cases,  however,  in  which  there  have  been  a  great  deal  of  injury 
and  much  loss  of  blood,  and  in  which  the  degree  of  shock  is  severe,  that  appar- 
ently do  better  if  the  operation  is  delayed,  providing  the  two  indications  just 
discussed — hemorrhage  and  pain — are  not  present. 

It  has  been  my  observation  that  in  traumatic  surgery  the  patients  exhibit- 
ing a  definite  clinical  picture  of  shock  do,  as  a  rule,  better  than  those  in  whom 
the  clinical  picture  of  shock  is  less  evident.  The  former  receive  appropriate 
treatment,  the  latter  are  apt  to  be  treated  on  the  supposition  that  shock  is 
absent.  In  looking  over  the  records  of  the  Johns  Hopkins  Hospital  Surgical 
Clinic  of  cases  of  primary  amputation  for  compound  fracture  and  other  crushed 
injuries  of  the  extremities,  I  find  a  few  examples  of  death  a  few  hours  after 
the  amputation,  from  shock.  In  examining  the  notes  of  these  cases  we  are 
impressed  by  the  fact  that,  if  shock  was  present  before  the  operation,  it  was 
not  recognized.  They  received  no  preliminary  treatment,  the  operations  were 
not  hastened,  but  a  careful,  painstaking  amputation  was  performed. 

On  the  other  hand,  the  patients  in  whom  the  local  injury  was  more  severe 
and  the  clinical  evidence  of  shock  M'as  unmistakable  have  recovered.  These 
patients  received  preliminary  treatment,  and  the  amputation  was  rapidly 
performed — in  the  older  cases  under  primary,  short  anesthesia;  in  some  recent 
cases,  under  anesthesia  associated  Avith  blocking  of  the  nerve  trunks.  No  at- 
tempt was  made  to  do  anything  more  than  rapidly  to  remove  the  mutilated  limb, 
cutting  through  miinjured  tissue. 


488  AJMERICAN  PRACTICE  OF  SURGERY. 

The  practical  deduction  from  tliis  is  tliat  m  all  cases  of  traumatic  surgery 
the  possibility  of  shock  must  be  borne  in  mind.  The  clinical  picture  is  often 
obscm'e:  we  have  no  means  of  estimating  accurately  the  exact  quantity  of 
blood  lost  before  admission  to  the  clinic.  For  this  reason  it  is  better  to  treat 
these  patients  on  the  principle  that  shock  is  present  to  a  considerable  degree 
and  that  a  great  deal  of  blood  has  been  lost  before  the  patient  came  under 
observation. 

In  my  o-uti  experience  loss  of  blood  is  the  most  dangerous  factor  in  these 
cases  of  traumatic  shock. 

Exposure  to  Cold. — Contributions  from  military  surgeons  indicate  that  ex- 
posure to  cold  is  a  distinct  element  in  increasing  the  degree  of  shock.  This 
factor  is  frequentty  present  in  traimaatic  surgery. 

Exposure  to  Heat. — That  biu-ns  may  produce  an  extreme  degree  of  shock 
has  been  discussed.  I  am  imable  to  find  any  literature  giving  observations 
on  the  relation  of  shock  to  high  temperatures;  that  is,  whether  injured  persons 
in  very  hot  climates  exhibit  a  degree  of  shock  out  of  proportion  to  the  character 
of  the  injury  and  the  loss  of  blood.  In  a  considerable  experience  of  my  own 
in  operations  during  the  severe  heat  of  the  summer  in  Baltimore  I  have  been 
unable  to  find  that  there  is  any  increased  mortalit}',  but  on  days  on  which 
the  temperature  has  been  very  high — over  90  or  95  degrees — I  have  been 
impressed  that  a  certain  number  of  cases  show  more  evidence  of  shock  at  the 
end  of  a  long  operation,  and  I  have  quite  frequently  postponed  operations 
of  unusual  magnitude  on  account  of  the  great  heat.  During  this  extreme  heat 
it  has  been  my  rule  to  have  ice  caps  placed  on  the  head  of  the  patient  during 
the  operation.  I  have  observed  a  few  cases  of  heat  stroke  during  operation 
and  a  few  of  heat  collapse.  I  have  never  been  called  upon  to  operate  upon  a 
patient  suffering  with  heat  prostration  or  heat  stroke.  In  alcoholics  I  am 
quite  convinced  that  deliriima  tremens  is  much  more  frecpent  during  the  hot 
season  of  the  year,  after  operations,  especially  for  injuries.  ^\Tien  secondary 
operations  are  necessary,  for  example,  for  infected  compotmd  fracture,  these 
patients  are  unusually  bad  subjects.  I  believe  that  in  critically  ill  patients 
extreme  degrees  of  heat  in  the  operating-room  should  be  considered  a  factor 
which  may  mcrease  the  shock,  and  precautions  should  be  taken  for  protection 
— ice  caps  to  the  head,  less  covering  to  the  body.  If  possible,  the  operation 
should  be  postponed,  or  performed  at  night  when  it  is  cooler. 

Atmospheric  Pressure. — Theoretically  the  blood  pressure  should  be  affected 
to  a  certain  degree  by  the  atmospheric  pressm'e.  Wliether  this  is  ever  a  factor 
in  shock  in  critically  ill  patients  I  am  not  prepared  to  say,  nor  have  I  been 
able  to  find  anj'  in^■estigations  on  this  point. 

Psychic  Factors. — To  what  extent  mental  conditions  can  produce  shock, 
or  exaggerate  it  when  present,  is  very  difficult  to  determine.  One  fre- 
quentty  observes  syncope  in  strong  individuals  from  the  loss  of  blood.     Fear 


SURGICAL  SHOCK.  489 

may  produce  a  general  condition  bordering  on  shock.  This  question  has  not 
been  investigated,  from  a  scientific  standpomt,  m  its  relation  to  practical 
surgery.  In  my  own  experience  all  these  mental  conditions,  which  may  be 
classified  mider  the  term  fright,  anxiety,  nervousness,  exaggerate  the  clinical 
picture  of  shock  when  it  is  present.  But  apparently  they  are  not  factors  of 
such  importance  as  those  already  discussed.  When  these  patients  are  nar- 
cotized the  pulse  and  respiration  immediately  improve.  The  importance 
of  studying  this  question  is  chiefly  from  the  standpoint  of  diagnosis.  The 
surgeon  might  easily  attribute  the  general  condition  of  the  patient  to  factors 
other  than  mental,  and  thus  be  led  to  erroneous  deductions  as  to  the  presence 
of  shock,  or  as  to  its  degree.  This  mental  factor  must  always  be  borne  in  mmd, 
but  it  is  a  dangerous  mistake  to  attribute  to  fear  or  nervousness  the  general 
condition  of  the  patient  when  in  reality  it  is  due  to  more  serious  conditions. 
This  mistake  is  much  more  to  be  guarded  against  than  the  reverse. 

I  have  never  been  able  to  convince  myself  that  these  mental  factors  are 
ever  of  sufficient  significance  to  influence  the  results,  as  far  as  mortality  is  con- 
cerned, of  traimiatic  or  any  other  form  of  surgery.  Nevertheless,  every  effort 
should  be  made  on  the  part  of  those  m  attendance  upon  the  patient  to  allay 
fear,  and  calm  all  nervous  or  other  anxieties.  The  ability  to  restore  the  patient 
to  a  quiet  and  confident  frame  of  mind  may  not  improve  the  immediate  and 
permanent  results  of  the  sm-gical  intervention;  nevertheless,  it  adds  so  much 
to  the  comfort  of  the  patient  that  every  effort  in  this  direction  should  be  made. 

In  operations  mider  local  anesthesia  we  observe  the  good  effect  of  this 
attitude  toward  the  patient.  It  has  been  called  "moral  anesthesia."  The 
surgeon  who  learns  the  art  of  this  method  can  perform  imder  local  ansesthesia 
many  operations  for  which  others  have  had  to  employ  general  anesthetics. 
This  is  well  illustrated  in  operations  for  exophthalmic  goitre.  If  the  surgeon 
gains  the  confidence  of  his  patient  and  is  able  to  control  the  nervous  element 
during  the  operation,  everything  goes  smoothly.  \^'Iien,  however,  this  control 
is  lost,  the  general  condition  of  the  patient  immediately  gets  worse — he  be- 
comes restless,  the  pulse  increases  in  rapidity,  the  respiration  is  labored,  and  not 
infrequently  it  is  impossible  to  finish  the  operation  without  a  general  anes- 
thetic. By  reason  of  its  relation  to  shock  I  believe  it  is  safer  to  use  general 
anesthesia  if  during  the  attempt  under  local  anesthesia  the  sm-geon  is  unable 
to  calm  and  control  his  patient  by  the  so-called  "moral  anesthesia." 

Yomiger  surgeons  especially  are  apt  to  miderestimate  these  mental  factors. 
Their  attitude  toward  patients  is  frequently  one  that  contributes  not  at  all 
to  the  mental  comfort  of  the  latter. 

Tact  and  cheerfulness  compatible  with  the  seriousness  of  the  patient's 
condition  are  the  two  most  important  attitudes  on  the  part  of  the  surgeon. 
At  the  same  time  he  should  never  allow  himself  to  exhibit  any  anxiety  or  give 
utterance  to  any  expression  which  could  be  interpreted  as  xmcertainty  in  regard 


490  AMERICAN  PRACTICE  OF  SURGERY. 

to  the  treatment  or  its  result.  As  stated  before,  we  have  no  definite  evi- 
dence that  this  so-called  moral  anaesthesia  or  treatment  materiallj'  affects  the 
ultimate  result. 

It  does,  however,  affect  the  comfort  of  the  patient,  and,  I  am  ciuite  convinced, 
is  one  of  the  most  important  factors  in  preventing  or  lessening  a  post-operative 
complication  which,  for  the  lack  of  a  better  term,  has  been  called  "  post-opera- 
tive neurosis." 

Summary  of  the  Etiological  Factors  in  Shock. — The  most  important  are  sen- 
sory impulses  affecting  the  medullary  centres,  the  next  is  hemorrhage.  General 
anaesthesia,  the  duration  of  the  operation,  extreme  degrees  of  heat  and  cold',  cer- 
tain drugs,  must  be  considered  additional  factors.  Although  their  influence 
has  not  been  proved,  psychical  effects  should  be  borne  in  mind.  As  general 
conditions  which  predispose  to  shock,  or  associated  with  which  the  important  fac- 
tors of  shock  act  with  greater  effect,  we  must  bear  in  mind  anaemia,  diabetes, 
nephritis,  alcoholism,  general  infection,  local  infections,  all  those  conditions 
which  interfere  with  metabolism  and  nutrition,  collected  under  the  term  "star- 
vation," and  auto-intoxication. 

The  sensory  impulses  which  produce  shock  may  be  the  result  of  traumatism, 
or  the  result  of  cutting,  tearing,  or  mutilating  tissues  during  an  operation. 

Only  those  organs  and  tissues  which  are  supplied  by  sensory  nerves  of  the 
cerebro-spinal  system  need  be  considered  in  relation  to  shock.  Their  sensibility 
is  increased  by  inflammatory  lesions. 

Organs  and  tissues  innervated  by  the  sympathetic  nerves  or  the  lower  vagus 
are  insensible,  and  at  the  present  time  we  have  no  evidence  that  their  manip- 
ulation or  injury  need  be  considered  as  factors  in  shock.  Tumors,  according 
to  Lennander,  are  insensible.  In  handling  these  insensible  tissues  it  is  unportant 
to  be  familiar  with  their  anatomical  relation  to  or  connection  with  surround- 
ing sensitive  tissues. 

Drugs  and  manipulations  which  in  experimental  investigations  and  clinical 
observations  produce  a  rise  in  the  blood  pressure  may  and  do  affect  the  vaso- 
motor centres  in  a  deleterious  sense  when  these  centres  are  exhausted.  Over- 
stimulation of  these  centres  may  be  just  as  dangerous  a  factor  as  a  primary 
depressant  or  inhibitory  action.  This  is  important  to  recollect  in  interpreting 
the  readings  of  a  blood-pressure  chart.  The  best  index  to  the  good  condition 
of  a  patient  durmg  an  operation  is  uniform  pressure.  Fluctuations  in  the  curve 
should  be  considered  indications  of  exliaustion.  Manipulations  which  produce 
a  sudden  and  considerable  rise  in  the  blood  pressure  should  be  interpreted 
as  overstimulation — factors  which  have  a  tendency  to  produce  shock.  It  is 
quite  true  that  drugs  like  chloroform,  or  any  manipulations,  or  loss  of  blood, 
which  produce  a  primary  fall  in  the  blood  pressure,  are  more  dangerous  factors 
than  those  which  produce  a  primary  rise,  but  both  must  be  considered  factors 
in  producing  shock.     In  the  employment  of  the  tonometer,  or  other  blood- 


SURGICAL  SHOCK.  491 

pressure-measuring  contrivances,  the  best  indication  of  the  good  condition  of 
the  patient  is  a  unijorm  pressure. 

DIAGNOSIS  OF  SHOCK. 

One  may  classify  surgical  patients  suffering  from  shock  into  three  groups : 
those  in  whom  shocls  is  associated  with  traumatic  injuries,  those  in  whom  it 
is  associated  with  some  disease,  and,  finally,  those  in  whom  the  shock  is  de- 
pendent upon  operative  intervention.  The  clinical  pictures  of  shock  in  all 
three  groups  are  very  much  alike.  However,  the  knowledge  of  the  previous 
history  of  the  patient  is  of  great  A^alue  in  determining  the  probabilit}'^  of  shock 
and  estimating  the  psychical  element  and  differentiating  it  from  the  physical. 

Extreme  degrees  of  shock  are  not  at  all  difficult  to  appreciate.  The  moderate 
degrees  and  the  conditions  which  predispose  to  shock  are  frequently  very  diffi- 
cult to  recognize ;  and  yet  a  diagnosis  in  this  stage  is  of  the  utmost  importance. 

Crile  differentiates  between  shock  and  collapse.  He  writes  that  the  term 
shock  should  be  used  for  that  condition  in  which  the  essential  phenomenon 
is  a  diminution  of  the  blood  pressure  and  the  etiology  of  which  is  an  exliaustion 
of  this  centre  of  varying  degrees  due  to  too  frequent  and  too  powerful  afferent 
stimuli.  The  term  collapse  should  be  confined  to  those  cases  in  which  the 
essential  phenomenon  is  a  sudden  fall  of  blood  pressure  due  to  hemorrhage, 
injuries  of  the  vasomotor  centre,  or  cardiac  failure.  In  shock,  therefore,  we 
have  an  exliaustion  of  the  centre;  in  collapse,  a  suspension  of  fmiction.  Practi- 
cally, it  is  very  difficult  to  differentiate  an  extreme  degree  of  shock  from  collapse. 

In  shock  in  traumatic  surgery  the  knowledge  of  the  amoimt  of  blood  lost 
and  the  nature  of  the  injury  is  of  great  value.  In  shock  associated  with  disease 
a  correct  diagnosis  of  the  lesion  and  an  accumulated  experience  with  operations 
upon  individuals  suffering  with  a  similar  disease  are  the  most  important  aids 
in  estimating  the  probabilities  and  degree  of  shock. 

In  operative  interventions  the  experimental  work  of  Crile  on  the  relation 
of  blood  pressure  to  the  different  manipulations  upon  the  different  tissues  and 
organs,  the  observations  of  Lennander  upon  the  sensibility  of  tissues,  and 
one's  experience  on  the  relation  of  the  different  operative  manipulations  to 
the  general  condition  of  the  patient,  allow  the  surgeon  to  estimate,  during  the 
operation,  with  a  considerable  degree  of  accuracy,  the  condition  of  the  patient, 
how  much  more  the  patient  can  stand  without  producing  a  degree  of  shock 
dangerous  to  life. 

W\\Qn  patients  are  under  a  general  narcosis  it  is  less  difficult  to  estunate 
the  degree  of  shock.  In  shock  associated  with  injury  and  disease — for  example, 
acute  pancreatitis,  intestinal  obstruction,  intestinal  perforation,  general  peri- 
tonitis, etc.,  etc. — it  is  frequently  difficult  to  determine  how  much  is  mental 
and  how  much  physical.  It  has  been  my  personal  experience  that  the  greater 
the  degree  of  shock  the  fewer  the  symptoms  which  may  be  classified  as  mental. 


492  AMERICAN   PRACTICE   OF   SURGERY. 

A  patient  in  a  condition  of  shock  is  quiet,  he  appears  somewhat  dazed;  although 
there  is  no  delirium,  the  action  of  the  mind  is  slow;  there  is  no  nervousness 
and  there  are  no  manifestations  which  might  be  called  h3'sterical.  The  pulse, 
as  a  rule,  is  rapid ;  the  blood  pressure,  if  measured,  will  be  f oimd  low.  The  skin 
and  mucous  membranes  are  pale.  The  temperature  is  frequentl}'  below  nor- 
mal. All  cutaneous  and  deep  reflexes  are  diminished,  thej'  maj''  be  absent. 
The  skin  feels  cold  and  as  a  rule  clammy.     The  respirations  are  shallow. 

A  rapid  pulse  is  by  no  means  an  indication  of  shock.  It  must  be  mter- 
preted  in  its  relation  to  other  factors.  A  blood-pressm'e  observation  is  of  the 
greatest  importance  to  interpret  the  significance  of  a  rapid  pulse.  In  exoph- 
thalmic goitre  the  pulse  is  rapid,  but  the  pressure  high ;  and  in  operations  upon 
patients  of  this  kmd  one  should  always  emploj^  a  tonometer.  In  nervous  and 
hj'sterical  patients  the  pulse  is  rapid,  but  the  blood  pressure  in  the  few  records 
at  my  disposal  is  nonnal  or  slightly  elevated. 

Cyanosis  should  be  considered  a  definite  indication  of  the  bad  condition  of 
the  patient. 

"\\lien  the  S5maptoms  are  chiefl}^  psychical  the  patient  is  flushed,  restless, 
anxious,  the  reflexes  are  increased,  all  sj-mptoms  are  exaggerated.  The  true 
mterpretation  of  these  sjmiptoms  is,  as  a  rule,  not  difficult.  They  disappear 
the  moment  the  patient  is  under  narcosis. 

From  this  discussion  it  is  to  be  seen  that  the  diagnosis  of  shock  is  at  the 
present  time  not  scientific.  We  have  not  sufficient  observations  on  blood  press- 
ure m  practical  surgery  to  allow  one  to  estmiate  the  degree  of  shock  by  the 
blood  pressure  alone.  The  diagnosis  of  shock  is  an  art  difficult  to  describe. 
It  is  based  upon  experience  and  the  proper  estimation  of  various  factors. 

Practically,  if  the  surgeon  will  bear  in  mind  all  the  points  previously  dis- 
cussed, he  will  be  able  to  estimate  the  condition  of  his  patient  before  and  during 
operation  with  sufficient  accuracj'  for  the  purposes  of  safety. 

PROGNOSIS. 

As  the  result  of  mjury  without  hemorrhage,  death  from  shock  seldom  takes 
place.  If  a  fatal  result  is  at  all  to  follow  an  injury  without  loss  of  blood,  death 
is  almost  instantaneous.  Recovery  from  shock  due  to  the  primary  effect  of 
the  uajmy  is  usually  permanent  and  immediate.  Sudden  death  after  an  in- 
jury should,  perhaps,  be  attributed  to  collapse,  as  described  by  Crile.  Sudden 
death  from  blows  upon  the  lower  chest  and  epigastrium  have  been  observed 
in  so-called  solar-plexiLs  blows,  well  loiown  in  pugilistic  encounters.  Accord- 
ing to  Crile's  experimental  research  the  collapse  is  due  to  the  effect  upon  the 
heart;  the  solar  plexus  may  be  disregarded  as  a  factor. 

Even  in  the  extreme  degrees  of  shock  from  injury,  if  the  patient  shows  any 
symptoms  of  reaction,  the  prognosis  for  recovery  is  good,  provided  no  further 
operative  intervention  is  necessar}^ 


SURGICAL   SHOCK.  493 

The  prognosis  of  shock  due  to  operative  intervention  depends  very  much 
upon  the  condition  of  the  patient.  Recovery  from  an  extreme  degree  of  shock 
usually  takes  place  if  the  patient  was  in  good  condition  before  the  operation  and 
provided  that  when  the  symptoms  of  shock  appear  the  administration  of  an 
anffisthetic  and  operative  intervention  can  immediately  be  suspended. 

Wlien  hemorrhage  is  one  of  the  factors  in  shock,  whether  it  be  due  to  injury 
or  to  an  operation,  the  prognosis  is  not  so  good.  Death  may  not  be  immedi- 
ate, but  a  patient  exsanguinated  reacts  much  less  quickly,  and  the  dangers  of 
secondary  complications  are  very  much  greater  than  they  are  in  those  cases  of 
shock  which  are  not  associated  with  hemorrhage. 

TREATMENT  OF  SHOCK. 

At  the  present  time  the  consensus  of  opinion  favors  a  treatment  which  is 
simple  and,  on  the  whole,  passive.  In  the  presence  of  shock  nothing  should 
be  done  which,  with  our  present  knowledge,  may  increase  the  condition.  The 
patient  should  be  kept  absolutely  quiet,  flat  on  the  back,  in  an  elevated  posi- 
tion, with  the  head  low.  The  body  temperature  should  be  maintained  by 
artificial  heat.  Only  one  drug  is  indicated  hypodermatically — morphine. 
This  is  indicated  in  small  doses  in  all  cases.  Its  quieting  effect  undoubtedly 
is  beneficial.  When  the  patient  is  suffering  pain,  sufficient  morphia  should 
be  given  to  relieve  this  pain.  Salt  solution  given  subcutaneously  and  by  enema 
is  indicated  in  all  cases.  When  there  has  been  hemorrhage  the  quantity  ad- 
ministered subcutaneously  should  be  greater.  If  the  patient's  condition  is 
critical  the  salt  solution  should  be  given  intravenously;  the  quantity  should 
vary  from  500  to  1,000  c.c.  In  very  critical  cases  associated  with  much  loss 
of  blood  the  intravenous  infusion  should  be  given  rapidly;  in  patients  less 
critically  ill,  more  slowly.  When  the  shock  is  not  associated  with  hemorrhage, 
according  to  Crile's  experimental  work,  the  administration  of  the  salt  solution 
subcutaneously  and  intravenously  has  not  given  evidence  of  great  value.  In 
practical  surgery  the  clinical  evidence  favors  the  employment  of  salt  solution 
in  all  cases.  But,  as  a  matter  of  fact,  in  traumatic  and  operative  surgery  the 
majority  of  cases  of  shock  are  associated  with  hemorrhage,  and  for  this  rea- 
son salt  solution,  of  course,  gives  evidence  of  its  great  value.  In  the  other 
cases  of  shock  without  hemorrhage,  the  prognosis  is,  as  a  rule,  so  good  that  it 
is  difficult  to  estimate  the  value  of  salt  infusion.  We  know,  however,  both 
from  experimental  and  from  clinical  evidence  that  it  is  not  harmful.  For  this 
reason,  salt  solution  should  be  employed  in  all  cases,  intravenously,  subcutane- 
ously, or  by  enemata,  according  to  the  condition  of  the  patient. 

Crile's  experimental  work  has  demonstrated  that,  in  shock,  what  is  required 
is  not  a  cardiac  or  a  vasomotor  stimulant,  but  some  agent  which  will  produce 
contraction  of  the  peripheral  vessels.     The  chief  danger  in  shock  is  a  dilatation 


494  AMERICAN   PRACTICE   OF   SURGERY. 

of  the  vessels  to  such  a  degree  that  the  patient  practically  bleeds  to  death 
within  his  own  vascular  system.  This  contraction  of  the  peripheral  circulation 
can  be  accomplished  by  bandaging  the  limbs  and  abdomen,  or  by  the  employ- 
ment of  Crile's  pneumatic  rubber  suit  which  accomplishes  the  same  object 
by  increasing  the  atmospheric  pressure.   (Figs.  140  and  141). 

From  the  experimental  work  of  Crile  and  others,  adrenalin  is  the  only  drug 
which  produces  vaso-constriction  by  its  action  on  the  peripheral  vessels.  Un- 
fortunately, at  the  present  time  the  clinical  evidence  in  favor  of  its  employment 
is  lacking. 

If  we  were  quite  certain  that  this  use  of  adrenalin  had  no  elements  of  danger, 
it  should  be  employed  in  all  cases.  But  at  the  present  time  the  evidence  in 
favor  of  its  value  is  not  sufficiently  positive  to  warrant  us  in  assuming  the  risks 
of  its  employment,  except  in  desperate  cases.  Then  it  should  be  given  intra- 
venously in  salt  solution  and  slowly. 

In  the  treatment  of  patients  suffering  from  traumatic  or  operative  shock 
I  employ  position,  artificial  heat,  bandaging  of  the  limbs  and  abdomen,  mor- 
phine, and  salt  solution.  I  agree  with  Crile  and  others  that  strychnine  and 
cardiac  stimulants  are  of  no  value  and  may  be  injurious. 

A  certain  number  of  patients  with  traumatic  and  operative  shock  die  in 
spite  of  all  measures  for  their  relief.  In  these  cases  there  has  usually  been 
hemorrhage. 

Now  and  then,  during  the  operation,  and  less  frequently  shortly  after  oper- 
ation, the  patient's  condition  may  suddenly  become  critical,  frequently  with- 
out previous  warning,  and  death  may  take  place  in  spite  of  treatment.  These 
may  be  considered  examples  of  "emergency  shock."  The  sudden  change  in 
the  pulse  and  respiration  is  so  rapid  and  the  evidence  of  impending  death  is 
so  manifest  that  it  is  difficult  not  only  to  ascertain  the  cause  of  the  collapse,  but 
also  to  know  what  is  to  be  done  for  its  relief.  In  some  of  these  cases  it  may 
be  the  anesthetic;  in  others  it  may  be  the  cardiac  shock  described  by  How- 
ell. Crile  is  of  the  opinion  that  in  some  of  the  cases  the  condition  is  due  to  a 
sudden  dilatation  of  the  heart.  At  the  present  time  it  is  difficult  to  state 
whether  anything  can  be  done  for  the  relief  of  these  patients.  Fortunately, 
the  number  of  such  cases  is  small.     The  problem  needs  further  investigation. 

Salt  Solution. — The  solution  used  for  subcutaneous  and  intravenous  infusion 
in  the  surgical  clinic  of  the  Johns  Hopkins  Hospital  is  as  follows: 

Sodium  chloride  (NaCl) 0.9 

Calcium  chloride  (CaCl) 0.01 

Potassium  chloride  (KCl) 0.03 

Distilled  water  (H..0) 99.06 

This  stock  solution  is  prepared  by  the  druggist.  The  nurse  in  charge  of 
the  operating-room  takes  50  c.c.  of  this  stock  solution  and  adds  it  to  950  c.c.  of 
distilled  water.     This  solution  just  fills  a  liter  glass  flask.     The  flask  is  corked 


SURGICAL   SHOCK.  495 

with  cotton,  covered  with  muslin,  which  is  properly  tied  to  the  neck  of  the  flask. 
These  flasks  are  sterilized  by  steam  under  pressure  and  are  ready  for  use  at  any 
time.  I  do  not  think  that  an  exact  temperature  of  the  solution  is  necessary. 
The  flask  filled  with  its  solution  is  inunersed  in  boiling  water  until  it  reaches 
a  temperature  of  100°  to  105°  F.  It  is  then  poured  into  a  glass  infusion  appa- 
ratus or  an  ordinary  rubber  douche  bag,  each  provided  with  a  long  piece  of 
rubber  tubing.  Both  should  be  sterilized  by  boiling.  They  can  be  wrapped 
in  towels  and  sterilized  by  steam,  and  in  this  manner  are  ready  for  emergencies. 
For  subcutaneous  infusion  an  ordinary  aspirating  needle  (Fig.  138)  is  attached  to 


a  small  piece  of  rubber  tubing  in  the  end  of  which  is  a  short  glass  tube.  This  is 
boiled  with  the  instruments.  When  a  subcutaneous  infusion  is  indicated  the  skin 
along  the  pectoral  border  of  the  breast  is  cleansed,  the  flask  is  filled  with  salt 
solution,  the  needle  is  attached  by  telescoping  its  glass  tube  end  into  the  long 
rubber  tube,  the  salt  solution  is  allowed  to  run  out  of  the  needle,  the  tempera- 
ture tested  on  the  skin  of  the  arm,  the  needle  is  then  introduced  just  below  the 
border  of  the  pectoral  muscle,  parallel  with  it  in  the  direction  of  the  axilla. 
This  allows  the  solution  to  infiltrate  the  tissues  in  the  base  of  the  axilla  which 
are  very  vascular,  and  absorption  takes  place  rapidly.  In  ordinary  cases  500 
c.c.  should  be  allowed  to  take  at  least  twenty  minutes  to  pass  from  the  flask 
into  the  tissues. 

The  same  method  is  suitable  for  intravenous  infusion,  except  that  a  differ- 
ent needle  should  be  employed,  one  like  that  shown  in  the  accompanying  cut 
(Fig.  139).  As  to  the  locaHty  where  the  injection  should  be  made,  I  prefer  one 
of  the  superficial  veins  at  the  bend  of  the  elbow. 

Adrenalin  Solution — Brewer  of  New  York  advises  15  minims  of  the 
1  : 1,000  commercial  solution  to  1,000  c.c.  of  normal  salt  solution;  as  a  rule,  not 
more  than  500  c.c.  should  be  given  intravenously;  if  possible,  a  blood-pressure 


apparatus  should  be  employed  at  the  same  time.  As  the  blood  pressure  rises 
the  infusion  should  be  checked.  If  the  blood  pressure  falls  again,  the  infusion 
should  be  resumed.  Precordial  pain  is  a  contraindication  for  the  further  em- 
ployment of  this  method. 

Wainwright  employs  the  adrenalin  solution  in  the  proportion  of  1  dram 
of  the  1 : 1,000  solution  to  2,000  c.c.  of  salt  solution. 


496 


AMERICAN  PRACTICE  OF  SURGERY. 


Fig.  IJO. — Crile's  Pneumatic  Suit  Adjust edfor  an  Operation  upon  the  Neck.     View  taken  from  one  side. 


Fig.  141. — Front  View  of  Crile's  Pneumatic  Suit  Adjusted. 


SURGICAL  SHOCK.  497 

Crile's  Pneumatic  Suit. —  Figs.  140  and  141  illustrate  a  patient  dressed  in 
this  suit.  It  has  been  placed  on  the  market  by  the  Goodrich  Rubber  Company 
of  Akron,  Ohio,  with  directions  for  its  employment. 

In  the  treatment  of  traumatic  shock  the  most  important  question  to  decide, 
if  operation  is  indicated,  is,  when  should  this  be  done?  This  has  been  dis- 
cussed. 

In  the  treatment  of  shock  during  operation  the  most  important  factors 
are:  the  exact  knowledge  of  the  patient's  condition  before  operation;  a  close 
watching  of  his  condition  during  operation,  so  that  the  surgeon  may  at  once 
become  cognizant  of  the  first  symptoms  of  shock.  When  these  symptoms 
arise,  it  is  the  art  of  surgery  to  be  able  to  estimate  how  much  more  the  patient 
can  stand,  because  the  most  important  features  of  treatment  are  to  withdraw 
the  anaesthesia  and  cease  operative  manipulations.  The  routine  treatment 
of  shock  has  not  much  value,  if  anaesthesia  and  operative  manipulations  must 
be  continued.  If  continuation  of  the  operation  is  absolutely  necessary,  the 
patient's  head  should  be  lowered  and  an  intravenous  or  subcutaneous  infusion 
given.  But  a  surgeon  runs  great  risks  if  he  continues  to  give  anaesthesia  and 
proceeds  with  the  operation  after  symptoms  of'shock  manifest  themselves. 

Any  stimulating  treatment  in  the  beginning  of  an  operation  is  contraindi- 
cated.  It  undoubtedly  masks  and  retards  the  symptoms  of  shock,  so  that 
when  the  patient  does  give  evidence  of  shock  the  condition  becomes  rapidly 
more  critical. 

VOL.  I.— 33 


PART  III. 

GENERAL  SURGICAL  DIAGNOSIS. 


GENERAL  SURGICAL  DIAGNOSIS. 

By  JOSEPH  D.  BRYANT,  M.D.,  New  York  City. 


The  principles  in  surgical  diagnosis  are  certain  fixed,  essential  truths  relating 
to  the  diagnosis  of  surgical  afflictions,  which  truths  are  the  legitimate  outcome 
of  surgical  experience  and  experiment,  and  which  are  employed  by  the  surgeon 
to  determine  the  presence  and  measure  the  comparative  significance  of  sur- 
gical disorders.  The  principles  in  surgical  diagnosis  are  properly  divided  into 
the  general  and  the  special  principles.  The  general  principles  in  surgical  diag- 
nosis relate  to  certain  diagnostic  truths,  to  which  there  are  no  exceptions  within 
the  scope  of  their  application;  i.e.,  pain  is  a  general  symptom  of  surgical  afflic- 
tion. The  special  principles  in  surgical  diagnosis  relate  to  diagnostic  truths 
having  a  special  relation  to  certain  general  or  local  surgical  afflictions,  but  not 
necessarily  having  a  like  connection  with  other  surgical  ills;  i.e.,  pain  character- 
izes neuralgia,  and  not  paralysis. 

The  constant  advance  of  the  science  of  surgery  develops  new  principles 
in  diagnosis,  and  also  correspondingly  lessens  the  value  of  principles  of  former 
importance,  often  indeed  rendering  them  inoperative.  The  general  morbid 
conditions  of  the  human  body,  whether  of  a  surgical  or  of  a  medical  nature, 
have  an  expression  of  their  own,  called  the  signs  and  symptoms.  Also  each 
special  affliction  of  either  condition  has  its  own  distinctive  form  of  expression, 
by  means  of  which  it  can  be  recognized  from  another  of  the  same  class.  A 
variety  of  affliction  of  a  definite  sort,  with  a  form  of  expression  common  to 
itself,  may  be  obscured  and  its  presence  lost  sight  of  because  of  the  unexpected 
intrusion  of  a  dissimilar  affliction  with  manifestations  peculiar  only  to  itself, 
called,  if  you  will,  a  complication  of  the  primary  trouble.  Also  many  of  the 
tissues  of  the  human  body  have  each  an  expression  of  affliction  peculiar  to  it- 
self; i.e.,  the  serous  tissues  when  inflamed  develop  a  sharp,  darting  pain,  the 
cutaneous  a  dull,  throbbing  pain,  etc.  Briefly  stated,  medical  and  surgical 
afflictions  have  each  a  distinctive  language  which,  when  properly  interpreted, 
establishes  the  diagnosis  and  indicates  the  treatment,  and,  toOj  often  the  prog- 
nosis, and  possibly  the  sequels  of  the  affliction. 

It  is  believed  that  the  reader  will  have  noticed  that  surgery  and  medicine 
may  be  so  closely  associated  with  each  other  by  common  forms  of  expression 
as  to  be  quite  inseparable;  therefore,  a  surgeon  ought  to  be  in  most  instances 
as  good  an  interpreter  of  symptoms  as  a  demonstrator  of  surgical  technique. 
The  surgeon  should  be  fully  equipped  with  practical  knowledge,  supplemented 

501 


502  AMERICAN  PRACTICE  OF  SURGERY. 

by  a  well-grounded  understanding  of  anatoni}^,  physiolog}',  chemistry,  pathol- 
ogy, etc.,  and  a  correct  estimation  of  the  phenomena  relating  to  the  fluids  of 
the  body  in  health  and  in  disease. 

Mechanical  and  other  practical  devices  are  as  much  a  part  of  the  outfit  of 
a  well-equipped  surgeon  as  of  the  physician.  In  fact,  no  means  fitted  to  aid 
in  determining  the  essential  facts  in  surgical  diagnosis  should  be  absent  from 
the  surgeon's  armamentarium. 

It  is  not  amiss  at  this  time  to  observe  that  the  powers  of  human  reasoning 
in  diagnostic  attainment  are  apt  to  be  developed  in  direct  proportion  to  the 
paucity  of  other  means  of  reaching  final  conclusions  in  the  field  of  differential 
endeavor.  And,  conversely,  inductive  diagnostic  attainment  should  be  care- 
fully fostered  or  it  will  be  disabled  by  the  vigorous  assaults  made  on  reasoning 
effort  by  the  use  of  the  novel  expedients  employed  in  diagnosis ;  not  necessarily 
because  of  the  abundance  of  these  expedients,  nor  of  their  presence,  but  be- 
cause it  is  thoroughly  human  to  accomplish  a  perplexing  purpose  with  as  little 
effort  as  possible.  The  scant  danger  that  now  attends  "explorative  incision" 
is  not  unlikely  in  some  instances  to  encourage  a  degree  of  mental  contentment, 
inhibiting  the  reasoning  powers,  followed,  after  brief  and  unconvincing  effort, 
by  the  expression,  "Oh,  well!  an  explorative  incision  will  settle  it." 

Necessarily,  the  patient  is  the  embodiment  of  the  information  on  which  the 
diagnostician  must  depend  for  his  differential  conclusions.  Here,  as  in  other 
fields  of  interrogator}^  endeavor,  only  carefully  considered  plans  of  attaining 
a  comprehensive  knowledge  of  facts  relating  to  a  patient,  thoughtfully,  cour- 
teously, and  consistently  employed,  will  satisfactorily  accomplish  the  purpose. 
The  diagnostic  efforts  of  the  surgeon  should  be  exercised  in  all  respects  in  such 
a  manner  as  will  secure  frank  and  unreserved  concurrence  on  the  part  of  the 
patient.  In  the  absence  of  a  gracious  and  sympathetic  method  of  inquiry, 
comparatively  little  progress  will  follow  the  best-planned  endeavors  of  attain- 
ing the  requisite  knowledge.  Arbitrary,  unsympathetic,  and  indelicate  expres- 
sion or  manner  is  likely  at  once  to  inhibit  all  concurrent  action  of  the  patient 
related  to  diagnosis.  The  patient's  and  the  friends'  understanding  of  the 
direct  and  comparative  value  of  testimony  in  the  history  of  a  case  is  necessarily 
crude,  often  misjudged  and  misleading,  and  frequent!}^  of  little  practical  sig- 
nificance. Yet  the  earnest  desire  to  impart  information  which  these  efforts 
betoken  should  be  given  proper  respect,  duly  emphasized  by  the  pleasant  and 
patient  bearing  of  the  surgeon.  It  will  not  infrequently  happen,  for  good 
reasons  perhaps,  that  a  patient  will  decline  or  evade  answering  queries  deroga- 
tory to  his  own  sense  of  dignity  or  self-respect,  or  to  his  ideas  of  propriety, 
or  that  may  intrude  on  personal  secrets  or  a  sense  of  duty  to  himself  or  to 
another.  These  sentiments  should  be  respected  by  the  surgeon,  who,  without 
appearing  overinsistent,  may,  notwithstanding  these  obstacles,  be  able  to  ap- 
proximate the  truth  sufficiently  to  meet  the  aims  in  view. 


GENERAL  SURGICAL  DIAGNOSIS.  503 

In  all  matters  of  expediency  relating  to  the  questioning  of  patients,  due 
heed  should  be  given  to  their  standards  of  intelligence  and  of  culture,  their 
sense  of  refinement,  and  their  familiarity  with  unsavory  and  uncanny  topics 
and  associations.  Some  patients,  for  reasons  difficult  to  explain,  will,  after 
being  discreetly  humored-  by  the  surgeon,  freely  disclose  things  of  signal  impor- 
tance which  were  at  firkt  retained  with  tenacious  reserve.  The  most  delicate 
form  of  expression  and  manner,  untainted  with  any  irrelevant  references  or 
needless  allusions,  are  requisite  in  developing  the  facts  of  a  case  in  the  female 
sex,  especially  if  they  be  of  a  strictly  personal  nature  and  in  any  way  encroach 
on  a  high  standard  of  proper  inherent  female  propriety.  And  especially  is 
this  plan  of  action  necessary  in  instances  of  the  yoimg  and  the  unsophisticated 
of  the  female  sex,  and  with  those  whose  disinclination  to  co-operate  in  an 
effective  manner  needs  the  supporting  presence  and  encouragement  of  a  third 
person,  such  as  an  old  friend,  a  near  relative,  and  sometimes  the  mother  of  the 
patient.  Again,  sensitively  attuned  patients  of  either  sex  will  not  infrequently 
divulge  important  or  perturbing  facts  more  freely  and  fully  in  the  absence  of 
a  third  party,  especially  when  the  information  imparted  tends  in  any  way  to 
detract  from  the  dignity,  self-respect,  or  standing  of  the  patient. 

The  needless  exposure  of  the  person  of  a  patient  of  either  sex,  or  unneces- 
sary dalliance  of  any  sort,  as  in  the  use  of  instruments  or  in  physical  examina- 
tion, or  by  superfluous  and  irrelevant  talk,  especially  of  a  familiar  character, 
should  be  sedulously  avoided.  In  instances  of  special  examinations  of  female 
patients  of  instrumental  or  of  oral  kind,  the  near-to-hand  presence  of  a  third 
person  of  responsible  station  should  be  had;  and,  on  occasions  of  the  adminis- 
tration of  anaesthetics  for  diagnostic  or  other  purposes,  the  third  person  should 
be  present  in  the  room. 

It  should  be  remembered  that  patients  differ  naturally  from  one  another 
in  many  respects,  notably  in  constitutional  characteristics,  in  idiosyncrasies, 
methods  of  expression,  manner  of  bearing  inflictions  of  various  kinds  and  of  es- 
timating the  severity  of  pain  and  other  manifestations  of  injury  and  disease.  In 
other  words,  each  patient,  until  a  different  course  is  determined  upon,  should  be 
regarded  as  a  more  or  less  independent  factor  in  diagnostic  endeavor,  and  be 
estimated  accordingly  in  all  essential  particulars. 

The  use,  on  the  part  of  the  surgeon,  of  ambiguous  and  technical  expressions 
should  be  avoided,  and  only  such  terms  should  be  employed  in  diagnostic  effort 
as  are  of  easy  comprehension  by  patients  already  more  or  less  perturbed  by  the 
situation  and  by  the  fear  of  the  announcement,  by  the  surgeon,  of  unfavorable 
findings.  The  unlettered  often  mistake  the  application  of  common  words  or 
may  be  ignorant  of  their  existence.  Hence,  if  great  care  be  not  exercised  under 
these  circumstances  by  the  surgeon  in  taking  the  history  of  the  case,  he  will 
be  so  misled  as  to  negative  an  important  proposition  in  diagnosis.  "Have 
you  ever  been  injured  before?"  is  often  promptly  answered  by  the  patient  in 


504  AMERICAN  PRACTICE  OF  SURGERY. 

the  negative;  and,  if  the  answer  be  as  promptly  accepted,  it  will,  in  many  in- 
stances, destroy  the  preA'ious  history  of  the  case  in  this  important  respect. 
The  incorrectness  of  the  answer  is  due  to  the  forgetfulness  of  the  patient,  or  to 
a  failure  to  appreciate  the  import  of  the  inquiry  or  possibly  the  meaning  of  the 
word  injury  itself.  In  the  taking  of  the  history  of  a  case,  it  is  usually  a  better 
plan  to  permit  the  patient  to  make  a  preliminary  statement  of  his  case,  guided 
somewhat  b}'  the  surgeon,  if  need  be,  in  order  to  bring  out  the  logical  sequence 
of  events.  This  plan  of  action  lends  courage  and  gives  importance  to  the  patient, 
and,  when  advantageously  used  by  him,  hastens  a  correct  understanding  of  the 
truth,  especially  when  the  landmarks  thus  established  by  the  narrative  are 
utilized  by  the  surgeon  in  securing  a  more  detailed  expression  of  the  facts. 

Only  rarely,  indeed,  does  one  meet  with  a  patient  who  is  unable  to  give  an 
intelligent  account  of  his  o\\m  case,  even  when  aided  by  the  inquiring  surgeon. 
In  such  exceptional  cases  the  surgeon  can  hope  to  secure  sufficient  data  for  the 
formation  of  an  enlightened  opinion  only  by  paying  the  closest  attention  to  the 
patient's  statements  and  by  exercising  much  patience  and  forbearance.  Also 
it  should  be  remembered  that  the  correctness  of  a  diagnosis  and  the  promptness 
with  which  it  is  secured  depend,  not  only  on  the  complete  and  accurate  history 
of  the  case  in  all  respects,  but  also  on  the  experience,  the  knowledge,  and  the 
sagacity  of  the  surgeon.  It  is  not  sufficient  merely  to  give  the  proper  name  to 
the  disease,  but  the  extent  and  location  of  the  tissue  changes,  the  causes,  the 
present  and  prospective  complications,  the  treatment,  the  prognosis,  and  the 
sequels  should  each  be  given  due  weight  in  the  judgment  of  the  surgeon,  based 
on  intelligent  appreciation  of  the  information  gained  from  the  testimony  of  the 
afflicted  witness. 

Surgeons  of  large  experience  are  very  cautious  about  utilizing  the  elements 
of  probability  when  they  come  to  frame  a  diagnosis,  but  the  beginners,  the 
impatient,  and  those  whose  resources  are  still  undeveloped  and  who  have  yet 
to  feel  the  sting  of  frequent  and  mortifying  failure  are  very  apt  to  make  an  un- 
safe use  of  these  elements  and  to  draw  hasty  conclusions.  The  overconfidence 
and  inattention  born  of  extended  experience,  of  youthful  enthusiasm,  and  of 
pretentious  ignorance  are  certain  to  lead  with  distressing  frequency  to  igno- 
minious failure  in  diagnosis.  It  is  only  those  who  have  properly  trained  minds 
and  who  are  willing  to  gain  experience  by  honest  and  painstaking  labor  who 
can  expect  to  attain  eminence  as  diagnosticians. 

Finally,  a  word  of  caution  should  be  added  regarding  the  temptation  to  make 
long  or  distressing  examinations  of  patients  who  are  severely  afflicted  with 
weakness  or  pain,  with  no  other  object  in  view  than  that  of  making  a  prompt 
diagnosis.  Nor  should  the  mistaken  zeal  of  the  physician  or  surgeon  lead  him 
to  sacrifice  m  the  slightest  degree  a  patient's  chance  of  recovery  for  the  purpose 
of  forestalling  the  autopsy  findings. 

As  before  remarked,  "The  patient  is  the  embodiment  of  the  information  on 


GENERAL  SURGICAL  DIAGNOSIS.  505 

which  the  diagnostician  must  depend  for  his  differential  conclusions."  The 
oral  testimony  of  the  patient  and  that  obtained  by  careful  systematic  scrutiny 
of  his  person  and  of  the  fluids  of  his  body,  together  with  the  knowledge  gained 
by  the  surgeon  through  a  proper  interpretation  of  the  circumstances  relating 
to  the  case,  should,  in  the  great  majority  of  instances,  provide  sufficient  evidence 
for  the  determining  of  a  diagnosis. 

THE  EXAMINATION  OF  THE  PATIENT. 

In  examining  a  patient  for  diagnostic  purposes  certain  well-established  com- 
mon facts,  such  as  the  name,  age,  occupation,  habits,  family  history,  etc.,  of 
the  patient  should  be  given  precedence  for  apparent  reasons.  Afterward,  the 
line  of  inquiry  may  begin  with  an  analysis  of  the  first  onset  of  the  disease  sus- 
tained by  the  patient,  or  with  that  of  the  present  attack.  If  the  former  course 
be  adopted,  it  will  be  desirable  also  to  investigate  the  facts  relating  to  all  subse- 
quent attacks.  This  plan  may  be  denominated  the  direct  or  the  analytic  method 
of  procedure.  The  reverse  of  this  practice  may  be  employed  by  commencing 
the  examination  with  the  present  phenomena,  and  following  them  back  to  the 
beginning  of  the  affliction.  This  latter  method  is  denominated  the  synthetic 
method  of  procedure.  We  have  no  hesitation  in  expressing  a  strong  preference 
in  favor  of  the  former  method,  since  our  long  experience  with  it  has  amply 
justified  this  conclusion.  And  more  especially  are  its  advantages  apparent 
in  complicated  cases  and  those  with  long  and  varied  histories  of  disease  or  in- 
jury. In  instances  only  of  recent  injury  or  disease,  the  briefer  plan  of  analytic 
examination  may  be  utilized  at  first,  but  with  the  idea  of  later  estimating  the 
effect  of  remoter  troubles  on  the  patient's  welfare.  The  direct  or  analytic 
method  of  examination  places  before  the  surgeon  in  a  consecutive  and  logical 
manner  a  complete  general  history  of  a  patient,  and  any  omissions  in  this  re- 
spect will  be  due  to  the  lack  of  experience  of  the  examiner  or  the  failure  of  the 
patient  properly  to  comprehend  the  meaning  of  the  questions  submitted  for 
reply.  In  the  indirect  or  synthetic  method  of  examination  there  is  much  lia- 
bility of  overlooking  important  contributive  facts,  and,  too,  the  method  is  apt 
to  be  more  embarrassing  to  the  patient  and  perplexing  to  the  surgeon  than  is 
the  analytic  plan.  However,  in  instances  of  local  injury  and  in  other  afflictions 
with  brief  histories,  as  well  as  in  those  requiring  prompt  therapeutic  action, 
the  synthetic  plan  is  usually  preferable.  As  before  stated,  by  means  of  the 
analytic  plan  the  facts  of  a  case  are  gradually  revealed  in  a  logical  systematic 
manner,  disclosing  in  a  direct  way  their  mutual,  consecutive  relationship  with 
each  other  up  to  the  last  moment.  A  record  of  events  of  any  kind,  made  from 
the  beginning  to  the  finish,  is  much  more  likely  to  be  complete  and  effectively 
connected  than  when  the  synthetic  method  is  employed.  In  either  instance, 
however,  only  great  care,  fortified  by  a  thoughtful  and  painstaking  method 


506  a:mericax  practice  of  surgery. 

of  making  such  inquiries,  will  enable  the  surgeon  to  secure  a  complete  and  reliable 
history  of  a  case. 

Too  often  the  finding  of  an  unusual  or  striking  feature  in  the  history  of  a  case 
will  cause  the  examiner  to  lose  sight  of  the  main  purpose  in  view,  and  follow 
enticing  developments,  of  little  or  no  coutributive  importance,  to  obscure  and 
irrelevant  endings.  When,  in  the  course  of  the  taking  of  a  histor}^,  especially 
of  a  complex  nature,  an  imexpected  or  unusual  feature  appears,  the  fact  should 
be  specially  noted  and  reserved  for  later  analysis,  and  not  permitted  to  divert 
the  course  of  the  examination  from  the  regular  line  of  procedure. 

The  Maimer  of  Questioning  Patients.— Already  much  has  been  said  re- 
garding the  general  manner  of  the  examiner  toward  the  patient,  but  it  still 
remains  to  speak  definitely  of  the  arts  of  phrasing  and  so  systematizing  the 
questions  as  to  make  the  best  use  of  opportunity.  The  query  commonly 
addressed  by  us  to  a  patient  is,  "  Up  to  what  time  (year)  of  your  life  were  you 
perfectly  well?"  or,  "Were  j'ou  ever  ill  or  injured?  If  so,  what  was  the 
date  of  your  first  injmy  or  illiress?"  After  ascertaining  by  careful  analysis 
the  causes,  nature,  severity,  results,  and  other  important  features  of  the  first  of 
the  afflictions,  the  remaining  ones  should  be  given  a  similar  consideration.  The 
asking  of  a  patient,  "What  is  the  matter  with  you?"  or,  "What  is  your  com- 
plaint?" often  amuses  the  patient  and  sometimes  misleads  the  sm-geon,  causing 
the  former  to  reply,  with  comical  or  sententious  mien,  "I  came  to  you  to  find 
out,"  or  to  express  gravel}'  a  diagnosis  that  has  not  a  good  fomidation.  By 
the  former  reply  one  may  be  annoyed;  by  the  latter,  one  is  often  deceived. 
Therefore,  we  have  long  since  ceased  seriously  to  propound  these  questions, 
limiting  ourselves  in  this  respect  to  those  admitting  of  no  cavil  or  misunder- 
standing, such  as  "Of  what  do  you  complain?"  "How  long  have  you  been  ill?" 
or,  "How  long  ago  were  you  injured?"  etc.  These  are  entirely  proper  queries, 
calling  for  prompt  and  intelligent  replies,  leading  to  direct  and  logical  con- 
clusions. In  instances  of  traumatic  violence,  especially  in  those  depending 
on  a  fall  or  a  blow,  the  facts  relating  to  the  cause  and  the  distance  of  the  fall, 
the  manner  of  striking,  and  the  physical  characteristics  of  the  object  struck, 
together  with  the  immediate  effect  on  the  ability  of  the  patient  to  care  for 
himself  and  the  causes  of  the  hinderance  to  do  so,  are  matters  of  great  impor- 
tance that  should  be  ascertained  at  the  outset  in  a  systematic,  logical  man- 
ner. So  far  as  it  is  possible  to  do  this,  an  estimate  should  be  made  of  the 
results  likely  to  follow  a  blow  of  a  given  force. 

The  Circumstances  of  a  Case.— It  is  plain  that  it  is  of  great  importance, 
as  regards  both  the  diagnosis  and  the  prognosis,  that  all  the  circumstances  of 
a  case  should  be  ascertained  in  the  most  complete  manner;  and,  in  addition 
to  what  can  be  learned  hj  questioning,  there  should  be  a  most  careful  exam- 
ination of  the  organs  and  the  fluids  of  the  patient,  with  the  idea  of  disclosing 
any  subtle  or  obscure  threatenings  of  life.     The  securing  and  the  proper  grouping 


GENERAL  SURGICAL  DLA.GNOSIS.  507 

of  the  evidence  gained  by  all  examinations,  up  to  the  time  when  the  surgeon 
is  called  in,  constitute  the  history  of  the  case;  and  it  is  proper  to  say  in  this 
connection  that  a  well-taken  and  wisely  comprehended  history  constitutes 
the  true  route  to  correct  diagnosis  and  rational  treatment. 

Two  methods  of  examination  of  a  patient  are  commonly  practised — the 
general  and  the  special  method.  The  former  method  relates  to  information 
regarding  the  influence  of  age,  sex,  habits,  occupation,  family  history,  etc., 
on  the  afflicted  patient.  This  knowledge  is  gained  by  questioning  the  patient 
and  the  friends  and  relatives.  The  special  method  relates  to  information  gained 
by  the  personal  examination  of  the  patient  by  the  surgeon;  it  is  also  often  called 
the  special  examination.  It  is  manifest  that  both  general  and  special  exam- 
inations are  absolutely  essential  to  the  securing  of  reliable  conclusions. 

The  General  Examination  of  a  Patient. 

The  Age. — The  age  of  a  patient  exercises  a  striking  influence  on  the  nature, 
the  effect,  the  results,  and  correspondingh^  on  the  outcome  of  treatment,  of 
disease  or  injury.  AVhile  youth  is  decidedly  sensitive  to  shock  and  pain  and 
loss  of  blood,  yet  it  is  largely  exempt  from  the  weakening  influences  of  the 
responsibilities,  acts,  and  duties  incident  to  advancing  age.  The  subtle  effects 
of  physical  and  mental  strain,  of  deteriorating  practices,  and  the  natural  changes 
of  advancing  years  lessen  the  resisting  power  of  the  human  organism  in  almost 
a  direct  proportion  to  their  degree  and  extent.  For  these  reasons  children 
who  escape  the  effects  of  shock,  loss  of  blood,  severe  pain,  and  restlessness 
recover  in  an  astonishing  manner  from  injury  and  disease  that  often  promptly 
terminate  existence  in  adult  life.  Adult  patients  differ  in  endurance  from  one 
another  more  than  do  the  young.  Aged  patients  with  good  muscular  and  mental 
vigor,  well  nourished  but  not  adipose,  having  good  digestion,  sound  organs, 
and  pliable  vessels,  can  withstand  well  the  trials  of  physical  infliction  and 
may  be  classed  as  enduring  patients.  Patients,  however,  with  conditions 
the  reverse  of  these,  especially  when  complicated  with  alcoholic  influences, 
should  be  treated  with  conservative  deference,  as  they  often  promptly  succumb 
to  the  effects  of  even  comparatively  moderate  physical  punishment  or  to  the 
delirium  of  previous  alcoholic  excess.  The  common  manifestations  of  disease 
in  different  parts  of  the  body  have  different  meanings  at  different  ages. 

A  pain  in  the  knee  of  a  child  suggests  disease  of  the  hip ;  in  the  adult,  disease 
of  the  knee  itself.  A  pain  in  the  bladder  of  a  child  may  point  to  stone  in  the 
organ,  but  never  to  enlarged  prostate.  Tumors  having  similar  characteristics 
and  locations  in  the  young  and  the  old  have  different  natures  and  meanings; 
in  the  former  they  are,  as  a  rule,  innocent  growths;  in  the  latter  malignant. 
Enlargements  of  lymph  nodes  in  the  young  are  common,  often  indicating  simple 
irritation  or  tuberculous  infection;    in  the  adult  such  enlargements  are  infre- 


508  AMERICAN  PRACTICE   OF  SURGERY. 

quent  and  often  dependent  on  malignant  changes.  Injury  near  a  joint  in 
the  young  may  cause  diastasis,  but  never  in  the  adult,  for  manifest  reasons. 
Injuries  of  equal  force  are  more  liable  to  cause  fracture  in  the  adult  than  in 
a  young  person,  since  the  bones  break  the  easier  in  the  latter  class.  Cutaneous 
diseases  in  children  are  strongly  suggestive  of  one  of  the  exanthemata;  in 
adult  life  they  more  commonly  indicate  other  forms  of  infliction. 

The  Sex. — Women  withstand  operations  and  injuries  rather  better  than  do 
men,  a  difference  due  in  part  to  the  greater  patience  and  fortitude  of  the  former, 
increased  by  the  benefit  of  greater  temperance  and  discretion  in  things  that  so  often 
unfit  the  opposite  sex  for  the  patient  support  of  physical  hardship.  And,  too,  con- 
finement in  bed  and  general  inactivity  are  less  irksonie  to  the  female  than  to  the 
male  sex.  The  physical  and  psychical  natures  of  the  sexes  are  radically  dif- 
ferent in  health,  and  correspondingly  diverse  in  disease.  The  emotional  ele- 
ment dominates  the  female;  the  physical  and  the  unemotional  dominate  the 
male.  We  find,  therefore  in  the  female  not  infrequently  general  hysterical 
manifestations,  and  also  local  ones  referable  to  a  joint,  a  limb,  the  bladder, 
a  special  organ,  the  special  senses,  etc. — in  fact,  to  almost  any  part  of  the  body, 
and,  too,  presenting  rational,  or  unreasonable,  and  even  grotesque  character- 
istics. Later,  these  hysterical  patients  often  suffer  from  an  almost  omnipresent 
and  depressing  fear  of  cancer  of  the  uterus  or  breast,  even  to  the  end  of  life. 
It  rarely  happens,  however,  that  one  of  the  male  sex  exhibits  hysterical  mani- 
festations of  a  general  or  local  nature.  Commonly,  local  evidence  of  disease 
in  the  male  sex  justifies  the  belief  that  such  disease  actually  exists.  The  male 
sex,  like  the  female,  has  its  fears  of  impending  dangers,  but  of  a  different  nature. 
In  youth  and  during  advancing  manhood,  fear  of  heart  disease  is  apt  to  be 
the  uppermost  thought  in  the  patient's  mind,  followed  by  a  long  period  of 
comparative  mental  rest  in  this  respect.  In  advanced  years,  however,  he  is 
likely  again  to  be  disturbed  by  apprehensions  of  enlarging  prostate  and  of 
cerebral  apoplexy.  In  either  sex  in  these  circumstances  the  motto  of  the 
surgeon  should  be,  "Carefully  examine,  promptly  diagnosticate,  and  quickly 
remedy  a  real  or  imaginary  infliction."  It  is  proper  to  say  at  this  time  that  the 
inflictions  of  the  male  sex  are  largely  the  heritage  of  occupation,  of  exposure, 
of  mental  and  physical  hyper-activity,  and  of  bad  habits;  those  of  the  female, 
on  the  other  hand,  grow  out  of  the  complications  and  sequels  of  menstruation 
and  child-bearing,  combined  with  those  begotten  of  inactivity,  introspection, 
and  emotional  domination. 

The  Occupation. — The  occupation  of  a  patient  has,  indeed,  very  much  to 
do  with  the  nature,  the  severity,  and  the  outcome  of  disease  or  injury.  The 
occupation  itself  may  directly  cause  infliction  or  contribute  the  influences  that 
favor  its  occurrence  or  development.  Necrosis  of  the  jaw,  lead  colic,  soot- 
cancer  of  the  scrotum,  patella  bursitis,  olecranon  bursitis,  malignant  pustule, 
glanders,  etc.,  are  each  striking  examples  of  the  direct  influence  of  occupation 


GENERAL  SURGICAL  DIAGNOSIS.  509 

on  physical  ills  of  the  watchmaker,  the  painter  and  the  plumber,  the  chimney- 
sweep, the  scrub-woman,  the  miner,  the  tanner  or  the  wool-sorter,  and  the 
stableman,  respectively.  The  modern  chauffeur  contributes  by  his  calling, 
as  do  his  patrons  by  their  presence,  a  fair  share,  illustrative  of  the  relation- 
ship between  injury,  on  the  one  hand,  and  occupation  and  pastime  on  the  other. 
The  "glass  arm,"  the  rounded  shoulders,  the  curved  spine,  etc.,  testify  re- 
spectively that  the  baseball  pitcher,  the  tailor,  the  shoemaker,  and  the  farmer 
bear,  each  one,  the  indelible  stamp  of  his  calling.  Those  whose  avocations 
expose  them  to  the  allurements  of  overeating  and  drinking  and  of  late  hours, 
to  say  nothing  of  the  besetments  of  vice  that  often  attend  such  forms  of  busi- 
ness, are,  in  many  instances,  illy  equipped  to  withstand  even  minor  degrees  of 
injury  or  disease,  and  they  can  scarcely  hope  to  recover  from  injury  or  disease 
that  in  a  decided  degree  imperils  the  lives  of  those  who  have  in  the  past  given 
due  heed  to  personal  welfare. 

The  Habits. — Whether  or  not  the  patient  has  been  temperate,  virtuous, 
and  law-abiding  is  of  great  significance  in  estimating  the  probable  results  in 
instances  of  grave  injury  or  disease.  The  liability  on  the  part  of  those  who  in- 
dulge in  excessive  eating  or  drinking,  of  contracting  a  disease,  or  of  directly  or 
indirectly  fostering  its  development  by  such  habits,  is  of  vicious  import  in 
lessening  human  vitality.  The  manner  of  dress,  the  habits  of  labor,  the  periods 
and  methods  of  recreation,  the  amount  and  the  character  of  the  food  and  the 
regularity  of  eating,  along  with  the  use  of  narcotics,  are  matters  that  exercise  an 
influence  for  good  or  for  evil  on  the  patient,  usually  in  direct  proportion  to  the 
excess  of  indulgence.  Often,  however,  for  reasons  difficult  clearly  to  define,  what 
are  apparently  indulgences  for  one  person  will  promptly  bring  to  grief  another 
less  immune  than  he  to  their  effects.  It  is  important  to  remember  that  the 
virtuous  may  bear  innocently  and  unsuspectedly  the  evidence  of  impure  asso- 
ciations and  their  sequels.  In  such  cases  as  these  the  surgeon  should  exercise 
great  discretion;  otherwise  irremediable  sorrow  and  perhaps  unmerited  dis- 
grace will  be  unwisely  added  to  distressing  affliction. 

The  Antecedent  History.— The  antecedent  history  of  a  case  should  in- 
clude, not  only  the  past  record  of  the  patient  in  all  matters  relating  to  disease 
or  to  injury,  but  also,  when  the  question  of  disease  is  involved,  that  of  his  an- 
cestors. Either  a  special  or  a  general  invulnerability  to  disease  on  the  part 
of  a  forebear  may  be  transmitted,  and  when  this  happens  it  may  manifest  itself 
primarily  in  the  first  generation,  sometimes  in  the  second,  and  perhaps  even 
in  a  later  generation.  According  to  Colles,  syphilis  of  the  child  means  syphilis 
of  the  mother,  whether  or  not  the  mother  shows  other  symptoms  of  the  disease. 
The  child,  however,  will  infect  the  nurse.  It  not  infrequently  occurs  that  a 
young  patient  with  pronounced  or  scanty  manifestations  of  glandular,  nervous, 
ocular,  auditory,  or  other  symptons  of  disease  is  allied  remotely  or  immediately 
•with  unsound  ancestry  bearing  a  history  strongly  suggestive  of  syphilitic  or 


510  AMERICAN  PRACTICE  OF  SURGERY. 

tuberculous  infection.  In  such  cases  as  these,  especially  those  suspected  of  a 
S3'philitic  taint,  wise  discretion  should  prompt  the  surgeon  to  employ  the  requi- 
site treatment  without  arousing  incriminating  suspicion  on  the  part  of  those 
who  maj'  regard  with  justifiable  pride  the  praiseworthy  records  of  an  honored 
ancestry.  The  recognition  of  certain  family  characteristics  compels  the  belief 
that  rheumatism,  gout,  hsemophilia,  color-blindness,  tumors  of  a  simple  or  of 
a  malignant  nature,  are  apt  to  be  transmitted  from  parents  to  their  offspring. 
Tliat  this  should  be  so  is  emphasized  by  the  well-knowm  facts  of  the  transmission 
of  personal  distinguishing  traits  from  parents  to  children.  In  view  of  the  fact 
that  there  are  numberless  instances  in  which  the  transmission  of  such  diseases 
has  not  taken  place,  we  should  be  admonished  not  to  give  too  great  heed  to 
coincident  marked  disease  in  those  who  bear  a  blood  relationship  to  the  patient. 
The  antecedent  history  of  a  patient  with  reference  to  disease  and  injury  falls 
better  for  consideration  under  the  personal  history  of  the  patient. 

The  Personal  History. — The  personal  history  of  a  patient  should  include 
a  record  of  his  personal  characteristics  as  well  as  of  the  diseases  and  injuries 
which  he  has  sustained,  and  of  their  outcome.  Incidentally,  his  habits,  more 
especially  the  objectionable  ones,  are  subject  to  review,  since  thej^  may 
have  a  very  important  bearing  on  the  prognosis  and  treatment  of  the  patient. 
The  temperament  of  a  patient  has  not  a  little  to  do  with  the  outcome  of  sur- 
gical injury  and  of  disease,  as  well  as  -with  the  results  of  operative  interference. 
The  patient  with  a  full  pulse,  vigorous  heart,  high  arterial  tension,  warm  surface, 
and  excitable  nature,  is  more  liable  to  unfavorable  reaction  from  injury  and 
surgical  effort  than  is  one  with  the  reverse  characteristics.  A  patient  with 
sluggishness  of  thought  and  action,  and  comparatively  iirdifterent  to  suffering 
and  confinement,  usually  bears  well  the  inflictions  of  physical  injury.  As  a 
general  proposition,  those  of  good  physical  vigor  bear  operations  better  than 
those  of  a  feeble  state.  However,  the  athlete  who  prides  himself  on  his  strength 
of  frame  and  fleetness  of  limb,  whose  entire  system  is  fitted  only  for  active 
effort,  is  unsuited  for  the  confinement  of  the  sick-room.  The  semi-invalid  and 
the  one  to  whom  confinement  and  inactivity  bring  no  special  regret  are,  other 
things  being  equal,  better  fitted  for  the  ordeals  of  an  operation  than  is  a  trained 
athlete.  When  expedient,  therefore,  the  former  class  should  serve  a  brief  pre- 
paratory period  in  confinement,  attended  with  free  tmloading  of  the  system 
by  the  emunctories,  before  an  operation  is  commenced. 

Tlie  obese  patient  is  ill  fitted  for  an  operation,  especially  when  the  obesity 
is  the  result  of  indolence,  luxm-y,  or  intemperance.  Hereditary  obesity  is  of 
less  moment  than  is  the  acquired,  especially  when  it  occiu-s  in  a  person  who 
has  not  been  able  to  exercise  control  over  his  appetite.  Physiologic  plethora, 
when  present  in  a  person  who  is  otherwise  phj^sically  and  functionally  vigorous, 
offers  no  obstacle  to  recovery  from  injury  or  disease,  or  to  the  securing  of  suc- 
cessful results  from  operative  effort;  but  the  acquired  plethora  of  the  tippler 


GENERAL  SUEGICAL  DIAGNOSIS.  511 

and  the  gourniand  should  be  as  a  beacon  warning  against  operative  practices 
not  supported  by  the  logic  of  expediency  and  not  protected  by  the  strictest 
modern  technique.  In  the  presence  of  an  obscure  or  incomprehensible  injury 
of  a  patient,  apparently  due  to  assault,  it  is  a  relief  to  know  that  it  may  be  de- 
pendent on  the  effects  of  alcohol  or  epilepsy.  On  the  other  hand,  a  knowledge 
of  the  fact  that  a  person  is  a  victim  of  epilepsy  may  spare  him  the  ignominy  of 
being  regarded  as  the  slave  of  intoxicants.  In  making  these  estimates,  however, 
it  must  be  remembered  that  a  liquor-laden  breath  does  not  surely  indicate  the 
habitual  use  of  alcoholic  drinks;  some  solicitous  friend  or  some  good  Samari- 
tan may  have  given  liquor  as  a  remedial  measure  to  a  patient  who  had  never 
before  experienced  its  taste. 

The  deformities  incident  to  a  previous  injury  of  a  patient,  especially  of  the 
skull  or  a  joint,  are  of  significant  import  in  estimating  the  gravity  of  a  recent 
injury  located  at  the  seat  of,  or  involving  the  functions  of,  the  part  previously 
injured.  The  history  of  a  previous  fracture  of  the  hip  or  thigh,  with  or  without 
shortening,  in  the  presence  of  a  recent  severe  injury  of  these  parts,  is  of  im- 
mense importance,  and  such  knowledge  may  be  absolutely  necessary  for  deter- 
mining the  degree  and  the  extent  of  the  present  injury. 

The  great  lesson  taught  by  the  preceding  facts  Is:  Carefully  take  the  his- 
tory of  the  case  if  you  expect  to  make  a  correct  diagnosis.  Whether  or  not  a 
patient  be  single  or  married,  happy  or  unhappy,  active  or  idle,  whether  sexual 
indulgence  be  occasional  or  frequent,  lawful  or  illicit,  are  each  a  matter  worthy 
of  careful  scrutiny  in  either  sex.  The  history  of  the  effects  of  menstruation, 
child-bearing,  miscarriages,  and  the  complications  and  sequels  of  parturition  on 
a  patient  ought  to  be  carefully  weighed. 

The  environment  of  a  patient  is  a  matter  of  great  importance,  siiice  those 
who  are  favored  with  healthy  surroundings  are  much  the  better  fitted  to  meet 
the  contingencies  of  injury  and  operative  practice.  Patients  who  are  exposed 
to  the  deteriorating  influences  of  special  miasms,  bad  ventilation,  damp  and  sun- 
less surroundings,  are  poorly  qualified  to  meet  physical  emergencies,  especially 
when  the  quantity,  quality,  and  amount  of  food  partaken  fall  short  of  the 
natural  demand.  Mental  emotions  of  a  depressing  nature,  such  as  apprehension, 
fear,  remorse,  disappointment,  etc.,  from  whatever  cause,  particularly  when  of 
a  direct  personal  bearing,  as  fear  of  the  outcome,  whether  real  or  imaginary, 
exercise  discouraging  effects  on  many  patients.  Steadfast  hope,  sure  and  abid- 
ing faith  in  the  medical  attendant,  aided  by  a  genial  and  philosophical  nature 
and  encouraging  associations,  contribute  more  to  a  successful  issue  in  many 
cases  than  the  faithful  utilization  of  the  therapeutic  agents  of  a  near-by  phar- 
macist. The  therapy  of  hope  wields  a  mighty  influence  in  recovery,  and  ought 
always  to  be  administered  with  a  free  hand  when  circmnstances  justify  such  a 
course. 

The  nature  of  a  morbid  growth  may  be  estimated,  with  considerable  proba- 


512  AMERICAN  PRACTICE  OF  SURGERY. 

bility  that  the  estimate  will  prove  to  be  correct,  by  the  length  of  time  that  it 
has  existed,  for  if  of  long  standing,  with  no  special  evidence  of  malignancy,  it 
may  be  regarded  for  the  time  as  an  innocent  growth.  On  the  other  hand,  a 
rapidly  increasing  local  growth,  attended  with  local  discomforting  symptoms, 
should  not  be  regarded  as  a  harmless  development,  but  should  be  promptly 
suspected  to  be  of  a  malignant  or  destructive  nature  until  otherwise  determined. 

It  appears  proper  at  this  time  to  assert  that  the  nature  of  a  growing  tumor 
should  be  investigated  at  once,  and  that  it  should  be  promptly  removed  when 
the  least  suspicion  of  malignanc)'  is  found. 

Enough  has  been  said  already  to  emphasize  the  great  importance  of  a  care- 
ful general  examination  of  a  patient  for  diagnostic  purposes.  Hardly  less 
than  this  would  suffice,  and  not  more  can  be  said  here  because  of  the  limited 
room  allotted  to  this  article. 

The  Special  Examination. 

The  special  examination  includes  the  physical,  both  being  of  a  general  charac- 
ter. The  examination  of  a  patient  may  be  conducted  to  a  final  conclusion  by 
the  combined  diagnostic  products  of  the  following  fields  of  inquiry: 

1.  Inquiry  by  the  unaided  senses  of  sight,  touch,  and  hearing,  and  some- 
times of  smell. 

2.  Inquiry  addressed  to  the  digestive,  respiratory,  circulatory,  nervous, 
locomotor,  and  genito-urinary  systems. 

3.  Inquiry  directed  to  examination  of  the  secretions,  the  excretions,  the 
discharges,  and  other  fluids  of  the  body  not  already  considered.  (See  the  article 
next  in  regular  order.) 

4.  Inquiry  facilitated  by  the  use  of  anesthetics  and  by  drugs  of  narcotic 
effect;  also  inquiry  supplemented  by  the  findings  of  explorative  and  operative 
aid. 

Simple  Inspection. — An  experienced  and  observing  surgeon  can  quickly 
determine  the  nature  of  certain  diseases  and  injuries  by  noting  the  posture 
of  the  patient  or  of  the  injured  part.  The  striking  signs  of  coxitis,  of  dislo- 
cation of  the  head  of  tlie  femur,  and  of  fracture  of  the  femur  are  such  as  to 
make  a  diagnosis  of  one  from  the  other,  by  means  of  inspection,  not  at  all  diffi- 
cult under  ordinary  circumstances.  The  dorsal  posture  of  a  patient  with  flexed 
limbs,  the  distended  abdomen,  the  thoracic  breathing,  and  the  anxious  facies 
suggest  so  decidedly  the  presence  of  peritonitis  as  to  require  strong  opposing 
evidence  to  effect  a  change  of  opinion.  A  patient  carrying  flexed  an  injured 
arm,  supported  by  the  opposite  hand,  with  the  head  inclined  to  the  injured  side, 
will  quite  likely  have  sustained  a  fracture  of  the  clavicle.  A  young  patient,  who 
in  walking  carries  the  body  straight  and  stiff,  with  the  shoulders  elevated;  who 
moves  with  a  shuffling  gait,  stepping  down  with  deliberation  and  care;  and 


GENERAL  SURGICAL  DL\GNOSIS.  513 

who,  on  standing,  leans  for  support  in  an  involuntary  manner  on  friendly  ob- 
jects, presents  a  familiar  picture  of  spinal  caries,  which  is  completed  beyond 
gainsay  when  the  patient  squats  instead  of  bending  forward  to  pick  an  object 
off  the  ground  or  floor.  A  patient  with  severe  injury  of  the  neck,  who,  with 
anxious  facies,  on  moving  grasps  firmly  the  head  between  the  hands,  rigidly 
holding  it  thus  while  turning  the  body  to  either  side  for  any  purpose,  may  have 
fracture  or  dislocation  of  the  cervical  spine.  The  sitting  posture  betokens 
oppressive  breathing,  more  especially  when  the  shoulders  are  fixed  by  contact 
of  the  upper  extremities  with  an  unyielding  support.  Involuntary  sliding  down 
in  beds  points  to  extreme  exhaustion.  A  patient  with  acute  pleurisy  from 
traumatism  or  disease,  or  one  with  pneumonia  from  the  same  cause,  will  lie 
upon  the  afflicted  side  so  as  to  limit  painful  motion.  In  pleuritic  effusion,  and 
sometimes  in  thoracic  aneurism  and  in  movable  abdominal  tumors,  the  patient 
will  lie  on  the  diseased  side  to  gain  the  increased  comfort  afforded  by  unhindered 
expansion  of  the  unaffected  side.  In  severe  colic  from  whatever  cause  patients 
usually  lie  in  the  lateral  position,  with  the  limbs  and  body  flexed  on  each  other; 
then  again,  in  severe  abdominal  colic,  in  gastric  ulcer,  in  aneurism,  and  in  verte- 
bral caries  patients  lie  on  the  abdomen  to  secure  the  relief  afforded  by  direct 
pressure,  as  well  as  that  which  comes  from  a  change  in  the  position  of  the  spine 
and  of  the  abdominal  contents.  The  color  of  the  skin,  the  state  of  nutrition 
of  the  body,  the  degree  of  muscular  development,  etc.,  are  each  important, 
as  indicating  whether  or  Hot  the  patient  be  temperate  or  ansemic,  or  be  suffer- 
ing from  disease  of  the  heart,  the  liver,  or  some  other  organ. 

The  superficial  or  pictorial  anatomical  appearances  of  definite  parts  of  the 
smiace  of  the  body,  as  related  to  injury  and  disease,  present  diagnostic  factors 
often  of  great  value.  In  order  properly  to  estimate  the  diagnostic  value  of 
abnormalities  in  appearance,  one  should  be  familiar  with  the  normal  surface 
outlines.  Owing  to  the  differences  which  naturally  exist  in  certain  regions 
of  the  body  in  health,  a  proper  estimate  of  the  changes  following  injury  or  dis- 
ease of  a  part  is  often  made  with  difficulty. 

The  Surface  of  the  Body. — In  examining  the  surface  of  the  body,  it  is  es- 
pecially essential  that  the  patient  be  placed  in  a  good  light  which  shall  fall  with 
equal  intensity  upon  corresponding  portions  of  the  surface,  i.e.,  the  abnormal 
and  the  normal.  The  patient  should  lie  straight,  or  sit  erect  if  practicable, 
with  the  limbs  placed  symmetrically.  The  influence  of  respiration  on  the  sym- 
metry and  movements  of  the  thorax  and  abdomen  should  receive  close  attention. 
Due  allowance  should  be  made  for  the  effects  of  an  uneciual  shedding  of  light 
on  a  part  and  for  any  abnormal  coloring  of  the  skin  dependent  on  disease  or  upon 
some  artifically  colored  rays  of  light. 

The  flattening  of  the  shoulders  due  to  fracture  of  the  acromion  process,  to 
dislocation  of  the  head  of  the  humerus,  or  to  atrophy  of  the  deltoid,  is  very 
liable  to  cause — even  in  the  mind  of  an  experienced  surgeon — perplexing  doubt 


514  AMERICAN   PRACTICE   OF   SURGERY. 

as  to  the  true  state  of  affairs.  The  outhne  of  the  spines  of  the  vertebral  column 
and  the  prominence  of  special  ones  are  matters  of  prime  importance,  as  undue 
deviations  of  the  former  and  increased  prominence  of  the  latter  bespeak  a  marked 
degree  of  lateral  curvature  and  of  antero-posterior  curvature  (Pott's  disease), 
respectively.  If  we  wish  to  render  more  evident  the  degree  of  lateral  deviation 
of  one  or  more  of  the  vertebral  spines,  it  is  only  necessary  to  rub  the  skin  with 
the  fingers  several  times,  with  some  degree  of  force,  over  these  bon}^  promi- 
nences.    The  skin  at  these  points  will  thus  be  rendered  red. 

Inspection  of  the  Thorax. — Inspection  of  the  thorax  enables  one  to  note 
whether  or  not  the  intercostal  spaces  and  the  respective  sides  of  the  chest  respond 
normally  to  the  respiratory  acts,  thus  determining  the  presence  or  absence, 
in  the  chest,  of  fluid  and  its  location.  Such  an  inspection  will,  at  the  same  time, 
reveal  to  us  whether  or  not  the  heart  be  much  enlarged  or  unduly  active,  and 
whether  the  thorax  be  symmetrical.  The  presence  of  collapsed  lung  or  of 
fractured  ribs  causes  restrained  respiratory  movements. 

Inspection  of  the  Neck. — The  two  sides  of  the  anterior  aspect  of  the  neck 
should  be  carefully  compared,  so  that  one  may  be  able  to  note,  later,  the 
slightest  abnormality  of  outline  or  of  action.  The  fact  that  malignant  disease, 
aneurism,  glandular  tumors,  bronchocele,  etc.,  are  not  infrequently  located  in 
this  intricately  constructed  and  important  region  sufficiently  emphasizes  the 
need  for  a  most  careful  examination  of  the  parts.  In  gunshot  or  stab  wounds 
of  this  region  emphysema  of  the  subcutaneous  tissue  of  the  neck  should  lead 
to  prompt  investigation  of  the  integrity  of  the  trachea,  the  oesophagus,  and  the 
lung.  The  circumscribed  areas  lying  directly  beneath  the  lobes  of  the  ear  are 
specially  worthy  of  stud}',  since  here  is  often  seen  the  earliest  evidence  of 
enlargement  of  the  parotid  gland  and  of  the  overlying  lymph  nodes. 

Inspection  of  the  Face. — The  distressing  tetanic  grin,  the  pinched  features, 
and  the  gasping  inspiration  of  approaching  dissolution,  the  involuntary  frown 
of  peritonitis,  and  the  facies  which  expresses  apprehension  of  the  torturuig 
spasms  so  frequent  in  acute  disease  of  joints  and  in  severe  neuralgias,  notably 
of  the  trifacial  type,  are  of  common  occurrence.  A  knowledge  of  the  relation- 
ship of  the  eyes  to  their  bony  environment  and  to  each  other  enables  the  sur- 
geon to  discover,  comparatively  early,  the  presence,  in  the  antrum,  of  a  rapidly 
increasing  growth,  encroaching  on  the  cavity  of  the  orbit  and  its  contents, 
and  consequently  to  adopt  the  necessary  surgical  measures  before  the  disease 
has  advanced  too  far. 

The  Abdomen. — The  surface  of  the  abdomen  should  be  inspected  with  care, 
so  that  abnormal  deviations  referable  to  the  outline,  color,  markings,  move- 
ments, and  the  circulation  may  be  quickly  noticed  and  their  significance  readily 
estimated.  For  example,  it  is  important,  in  making  the  distinction  between  a 
hernia,  on  the  one  hand,  and  a  hydrocele  or  a  scrotal  tumor,  on  the  other,  to 
note  whether  or  not  an  inguinal  tumor  first  appears  from  above  or  from  below. 


GENERAL  SURGICAL  DIAGNOSIS.  515 

or  remains  in  situ  wfien  the  patient  in  standing  or  when  he  is  lying  down;  and 
whether  it  does  or  does  not  convey  an  impulse  on  coughing.  Even  more  impor- 
tant in  many  respects  is  a  similar  scrutiny  of  the  femoral  areas,  for  here  hernia, 
abscess,  glandular  growths  of  simple,  specific,  and  malignant  natures  find  an 
open  door,  and,  unfortunately,  their  presence  and  nature  are  in  many  instances 
ascertained  too  late  to  permit  of  the  administering  of  satisfactory  relief.  The 
lymph  nodes  of  this  situation  freely  communicate  with  near-by  clusters  of  sim- 
ilar nodes,  offering  early  opportunity  for  extensive  infection.  Inspection,  es- 
pecially of  individuals  with  thin  abdominal  walls,  reveals  the  presence  of  intra- 
abdominal tumors  of  considerable  size,  and  also,  in  some  cases,  the  increased 
peristalsis  characteristic  of  intestinal  obstruction. 

The  Color.— In  the  diagnosis  of  disease  and  injury  color  plays  a  part  of  con- 
siderable importance.  The  scarlet  blush  of  acute  infiammation,  the  dusky 
red  of  subacute  inflammation  of  a  complicated  or  of  a  specific  character,  the 
mottled  hues  of  venous  obstruction  and  the  livid  one  of  asphyxia,  the  varying 
shades  of  color  observed  in  traumatism,  the  inky  aspect  of  dying  tissue,  the 
uncanny  pallor  of  anasarca,  and  the  sallow  and  waxy  hues  of  advanced  ma- 
lignancy— all  of  these  testify  in  some  measure  to  the  important  information 
which  color  may  convey. 

Translucency  of  a  diseased  part  can  be  quite  well  considered  in  connection 
with  color.  A  translucent  tumor  is  largely  made  up  of  a  thin,  colorless  fluid, 
as  in  hydrocele  of  the  scrotum  and  of  the  spermatic,  cord;  also  in  spina  bifida. 
The  normal  tissues  of  the  hand,  the  ear,  and  the  cheeks  are,  in  thin  persons, 
when  subjected  to  a  powerful  light,  fitted  to  the  purpose. 

Palpation. — On  the  abdomen,  more  particularly  than  elsewhere,  palpation 
should  be  practised  with  gentleness  and  care,  especially  when  the  part  thus 
examined  is  tender  or  inflamed  or  liable  to  be  bruised  or  ruptured  by  the 
act.  Incautious  palpation  of  a  diseased  appendix,  or  of  an  abcess  or  cyst,  may 
cause  prompt  rupture,  with  fatal  extravasation  of  the  contents.  In  palpating, 
the  hand  should  be  warm,  be  laid  flat  on  the  surface,  and  be  allowed  to  remain 
quiet  until  the  patient  and  the  part  are  reconciled  to  its  presence.  Circular 
or  to-and-fro  movements,  made  in  opposite  directions  and  gradually  increased 
in  force  and  area,  are  employed  to  determine  the  depth,  the  sensitiveness,  and 
the  mobility  of  the  deeper  parts  and  of  the  overlying  tissues.  If  the  move- 
ments are  too  vigorous  or  the  ends  of  the  fingers  are  carelessly  used  for  the  pur- 
pose at  first,  the  aims  of  the  measure  will  be  defeated  by  the  muscular  contrac- 
tions due  to  pain,  to  acute  expectancy  of  the  patient,  and  perhaps  to  irrational 
objections  as  well.  The  cautious  and  deliberate  use  of  the  ends  of  the  fingers 
in  palpation  enables  one  to  judge  of  the  size,  the  depth,  the  mobility,  and  the 
physical  characteristics  (hard,  soft,  elastic,  irregular,  etc.)  of  a  growth,  to  say 
nothing  of  the  degree  of  sensitiveness  of  the  parts.  By  palpation  we  determine 
the  presence  of  fluctuation  due  to  the  existence  of  fluid  in  the  tissues.     Muscular 


516  AMERICAN  PRACTICE  OF  SURGERY. 

fluctuation  may  be  mistaken  for  that  caused  by  the  presence  of  fluid,  unless 
the  muscles  be  palpated  in  the  long  axis  instead  of  the  transverse,  when  the  fal- 
lacy will  disappear. 

The  crackling  of  emphysema,  the  crepitus  of  fractures,  the  thrill  of  an  an- 
eurism, the  friction  of  roughened  synovial  and  serous  membranes,  and  the 
creaking  of  joints,  etc.,  are  easily  determined  by  means  of  palpation.  The 
weight  of  a  morbid  growth  springing  from  a  pendulous  part  of  the  body,  like 
the  mammary  glands,  or  the  testis,  or  that  of  a  pendulous  growth  elsewhere  lo- 
cated, is  determined  by  a  sense  related  to  that  of  touch;  and  since  malignant 
and  fibrous  growths  are  denser  than  those  of  a  fatty  or  cystic  nature,  this  ele- 
ment of  dissimilarity  may  be  of  use  in  differentiating  them.  An  estimate  of 
the  temperature  of  a  part,  like  the  estimate  of  its  weight,  can,  in  many  instances, 
be  made  by  touch  sufficiently  well  for  all  practical  purposes.  The  fallacies,  how- 
ever, that  maj'  arise  in  this  practice  are  numerous.  Thermometers  are  so  uni- 
versally available,  and  their  importance  as  an  aid  to  diagnosis  is  so  thoroughly 
established,  that  one  is  not  justified  in  placing  more  than  a  passing  reliance  on 
a  mere  maimal  estimate  of  the  temperature  of  a  patient. 

The  Examination  of  the  Principal  Systems  of  the  Body. 

The  principal  systems  of  the  body,  as  arranged  for  the  purposes  of  our  pres- 
ent study,  are  five  in  number,  viz.,  the  digestive,  the  respiratory,  the  circulatory, 
the  nervous,  and  the  genito-urinary  systems.  But  with  the  limited  amount 
of  space  at  our  disposal,  we  can  scarcely  hope  to  do  more  than  touch  very  lightly 
upon  the  questions  of  diagnosis  as  they  are  related  to  each  of  these  systems. 

The  Digestive  System. — The  digestive  system  comes  first  in  the  natural 
order  of  distribution,  and  it  also  deserves  that  position  on  account  of  its  com- 
manding importance. 

The  Lips. — The  smooth  lips  of  the  young,  the  pallid  lips  of  the  feeble,  and 
the  cyanosed  lips  of  those  with  deficient  aeration  of  the  blood  are  pictures  with 
a  significant  meaning.  The  unclosed  lips  of  dyspnoea,  when  parched  and  purple, 
indicate  acute  or  chronic  interference  with  the  proper  oxygenation  of  the  blood. 
A  downward  and  outward  deviation  of  one  angle  of  the  mouth  may  be  due  to 
loss  of  power  on  the  opposite  side,  or  to  undue  contraction  on  the  same  side, 
as  in  facial  paralysis  and  in  cicatricial  contraction  respectively.  The  swelling 
of  a  lip  may  suggest  traumatic  violence,  deep-seated  inflammation,  great  local 
irritation,  the  urticaria  of  idiosyncrasy,  the  bite  of  an  insect,  or  the  effect  of  an 
injury  inflicted  during  epileptic  convulsions.  A  fissure,  an  ulcer,  or  a  mucous 
patch  of  the  lip  are  lesions  which  suggest  a  specific  nature.  An  ulcer  of  the  lip 
with  induration  of  the  related  lymph  nodes  may  be  of  either  a  malignant  or  a 
specific  nature,  and  the  microscope  should  be  employed  to  determine  the  ques- 
tion. 


GENERAL  SURGICAL  DIAGNOSIS.  517 

The  Gums.— The  swollen  and  spongy  gums  of  scurvy,  the  blue  line  of  lead 
poisoning,  the  red  line  of  tuberculous  and  of  cancerous  cachexia  and  of  diabetes, 
and  the  pallor  of  anaemia  are  among  the  many  indications  of  disease  related  to 
the  gums. 

The  Teeth. — The  early  dentition  of  precocity  and  of  syphilitic  endowment, 
the  delayed  dentition  of  rickets  and  cretinism,  the  peg-shaped,  notched  teeth 
of  syphilitic  belonging,  the  teeth  with  dentated  edges  and  furrowed  surfaces  of 
bad  nutrition,  the  loosened  and  decayed  teeth  of  scurvy,  of  purpura,  and  of 
phosphorus  poisoning,  are  manifestations  of  great  diagnostic  value. 

The  Tongue. — The  tremulous  tongue  of  the  alcoholic,  the  halting  protrusion 
dependent  partly  upon  loss  of  muscular  power  and  partly  upon  mental  obtuse- 
ness,  the  genuine  deviations  caused  by  organic  paralysis,  the  apparent  devia- 
tions due  to  facial  paralysis,  are  of  diagnostic  importance.  The  smoker's 
patch,  the  syphilitic  mucous  patch,  the  chancrous,  the  tuberculous,  and  the 
malignant  ulcers  should  each  be  promptly  recognized  and  their  meaning  esti- 
mated. The  dry  tongue  of  mouth-breathing,  of  continuous  high  temperature, 
of  dehydration  of  the  body,  of  asthma,  of  prostration,  and  of  mental  emotions 
is  in  each  instance  significant. 

The  Palate,  Tonsils,  and  Pharynx. — The  offensive  odor  of  follicular  tonsil- 
litis, of  gangrene,  of  cancerous  and  syphilitic  ulcerations  should  be  noted. 
The  discoloration  of  the  palate  or  pharynx  due  to  venous  obstruction,  and 
the  presence  in  these  situations  of  circumscribed  hemorrhagic  points,  with 
or  without  the  escape  of  blood,  require  investigation.  Perforations  or  ulcera- 
tions of  the  hard  or  the  soft  palate  and  adhesions  of  the  latter  to  the  posterior 
pharyngeal  wall  point  to  syphilis.  Bilateral  paralysis  of  the  soft  palate  sug- 
gests diphtheria,  possibly  vertebral  caries;  unilateral  denotes  deep-seated  in- 
terference, as  in  intervertebral  pressure  and  fracture  of  the  base  of  the  skull. 
An  aneurism  in  close  proximity  to  the  faucial  tonsil  may  cause  the  latter  to 
pulsate.  Deep-seated  ulceration  of  the  tonsil  suggests  cancerous  or  syphilitic 
invasion  that  may  involve  the  internal  carotid  artery  and  cause  prompt  death 
from  hemorrhage.  Acute  tonsillitis  attended  by  deep  or  superficial  suppura- 
tion, especially  the  former,  displaces  the  tonsil  toward  the  median  line,  and 
calls  for  an  incision  to  afford  prompt  relief. 

In  exceptional  cases  the  tonsil  and  contiguous  tissues  may  be  the  seat  of 
an  extensive  invasion  of  malignant  disease  which  nevertheless  causes  so  little 
local  disturbance  as  to  fail  to  arouse  a  suspicion  of  serious  trouble. 

The  mucous  membrane  of  the  pharynx  is  liable  to  various  phases  of  disease 
of  simple,  specific,  or  malignant  nature;  it  is  also  subject  to  acute  and  chronic 
expressions  of  the  various  forms  of  pharyngitis.  The  pharynx  may  be  encroached 
upon  by  a  post^pharyngeal  abscess,  causing  slow  or  rapid  interference  with 
deglutition  and  respiration;  such  an  abscess  is  due  to  vertebral  caries  or  to 
some  deep-seated  infection  close  at  hand  or  more  distantly  located.     Difficulty 


518  AMERICAN  PRACTICE  OF  SURGERY. 

in  swallowing  may  also  result  from  rheumatic  lameness,  from  spasm,  from 
paralysis  of  the  muscles  of  the  larynx,  or  from  hydrophobia,  tetanus,  or  strj'ch- 
nine  poisoning. 

The  (EsoTphagus. — Stiffness  of  the  neck  due  to  acute  inflammation  of  the 
oesophagus  or  to  pre-ocsophageal  suppuration  simulates  that  which  is  depend- 
ent upon  traumatism  or  upon  rheumatic  invasion.  Diseases  invading  the 
mcuous  membrane  of  the  oesophagus  are  characterized  by  the  production 
of  a  glairy  and  sometimes  frothy  or  viscid  mucous  secretion,  which  is  dislodged 
by  hawking,  and  is  especially  abundant  in  acute  inflammation  and  cancer  of 
the  gullet.  Hemorrhage  of  the  oesophagus  usually  comes  from  the  lowor  end 
of  that  tube,  being  due  to  varicose  veins  or  to  obstructive  disease  of  the  liver 
or  heart,  especially  in  old  people;  it  also  may  come  from  intra-mediastinal 
pressure,  from  cancer  and  other  forms  of  ulcer,  and  also  from  the  presence 
of  a  foreign  body  or  from  a  severy  injury.  The  amount  of  blood  discharged 
is  usually  small,  alkaline,  of  bright  color,  and  not  mixed  with  the  contents  of 
the  stomach  unless  vomiting  has  happened.  Emphysema  in  the  connective 
tissues  of  the  neck  suggests  perforation  of  a  lung  or  of  the  trachea  or  of  the 
oesophagus.  In  the  latter  case  there  must  exist  a  communication  between 
the  oesophagus  and  the  trachea  or  one  of  the  deeper  bronchi,  such  a  condition 
being  due  in  all  probability  to  ulceration  or  to  a  wound  of  these  passages. 
When  obstruction  exists  in  the  course  of  the  oesophagus,  auscultation  to  the 
left  of  the  ninth  or  tenth  dorsal  vertebra  may  reveal  delayed  or  absent  second 
sound  of  normal  deglutition.  Any  pathological  change  causing  local  or  gen- 
eral enlargement  of  the  oesophagus  in  the  neck  can  be  felt  behind  the  trachea, 
usually  better  to  the  left  side.  Percussion  may  disclose  conditions  correspond- 
ing to  those  which  have  just  been  mentioned;  and  further  confirmation  may 
be  obtained  by  the  employment  of  the  a:-ray,  which  reveals  the  presence  of 
a  bright  area  (emptiness)  immediately  next  to  'a  dark  one  caused  by  the 
presence,  in  the  unequal  lumen,  of  a  mixture  of  bismuth  or  some  other  metallic 
salt  introduced  for  the  purposes  of  the  test. 

The  technique  and  the  danger  of  introducing  an  oesophageal  bougie  should 
be  well  understood.  In  this  connection  I  may  sa}^  that  the  examiner  will  do 
well  to  refresh  his  memory  regarding  the  size,  direction,  length,  and  other 
anatomical  characteristics  of  the  oesophagus,  and  also  to  studj^  well  the  diseases 
to  which  this  organ  is  liable,  in  order  that  he  may  not,  by  his  explorative 
procedures,  expose  the  patient  to  any  imusual  danger. 

The  Stomach. — The  general  anatomical  relations  and  characteristics  of  the 
stomach  cannot  properly  be  stated  here.  The  amoiait  of  information  that 
may  be  gained  by  an  examination  from  the  outside  is  largely  regulated  by 
the  degree  of  adiposity  of  the  abdominal  ^A'all  and  the  size  of  the  stomach. 
Usually,  when  the  patienl;  is  lying  on  his  back,  it  is  possible  to  outline  a  dis- 
tended stomach  by  the  surface  shadow  of  the  lower  border,  which  moves  with 


GENERAL  SURGICAL  DL\GNOSIS.  519 

the  respiratory  act.  Visible  gastric  peristalsis,  in  which  the  movement  pro- 
gresses from  the  left  costal  arch  downward  to  the  right,  is  an  indication  of 
pyloric  obstruction;  so  also  is  displacement  or  distention  of  the  organ,  con- 
ditions which  can  quite  readily  be  ascertained  b}^  the  modifications  of  the 
normal  percussion  and  succussion  areas,  etc.  By  transillumination  with  appro- 
priate apparatus  one  may  determine,  with  a  fair  degi'ee  of  accuracy,  the  size, 
shape,  and  location  of  the  stomach;  also  the  presence  of  tumors  and  such  other 
morbid  changes  of  the  viscera  and  contiguous  structures  as  may  modify  the 
transmission  of  light.  This  plan  of  investigation,  however,  along  with  that 
of  the  x-ray  and  bismuth  test,  should  supplement  rather  than  supplant  the 
findings  of  palpation.  Palpation  and  percussion  are  fertile  methods  of  ascer- 
taining the  truth  in  regard  to  conditions  of  the  stomach,  and  M^hen  combined 
they  are  the  most  conclusive  of  all.  The  method  of  palpation  already 
noted  should  be  practised  here,  and  its  efficiency  will  be  decidedly  in- 
creased by  placing  the  patient  in  the  knee-elbow  position,  thus  causing 
the  stomach  to  fall  forward  upon  the  abdominal  wall.  These  measures 
are  decidedly  enhanced  in  value  by  co-operative  action  on  the  part  of 
the  patient,  and  the  measure  of  success  obtained  will  depend  largely 
upon  the  degree  to  which  the  abdominal  muscles  are  relaxed,  the  thinness  of 
the  abdominal  wall,  and  the  size,  mobility,  and  degree  of  involvement  of  the 
stomach.  "\^Tien  all  these  conditions  are  unfavorable,  and  notably  when  they 
are  associated  with  pathological  changes  in  neighboring  organs,  it  becomes 
wellnigh-  impossible  to  make  a  diagnosis.  When  the  palpating  fingers  meet 
with  increased  resistance,  especially  of  an  unyielding,  hard,  and  irregular  nature, 
there  is  substantial  ground  for  suspecting  the  presence  of  a  cancer,  and  par- 
ticularly so  when  the  mass  occupies  the  usual  site  of  a  carcinoma  of  the  stomach. 
Although  cancer  of  the  pylorus  is  commonly  felt,  as  one  might  expect,  above  the 
navel  and  to  the  right  of  the  median  line,  it  sometimes  occupies  a  lower  posi- 
tion. When  the  tumor  is  confined  strictly  to  the  pylorus,  it  is  not  likely,  even 
though  it  may  be  freely  movable  from  side  to  side,  to  move  up  and  down  to  any 
extent  in  harmony  with  the  respiratory  moA^ements  of  the  diaphragm:  but, 
when  it  is  adherent  to  some  freely  movable  organ  like  the  liver  or  the  diaphragm, 
then  its  movements  will  correspond  to  those  of  the  part  to  which  it  is  adherent. 
Cancer  of  the  stomach  is  usually  a  small,  hard  mass  with  an  irregular  surface, 
while  cancer  of  the  neighboring  retroperitoneal  lymph  nodes  presents  a  broad 
surface,  also  hard  and  nodular,  but  influenced  little  or  not  at  all  by  the  respira- 
tory movements. 

When  palpation  in  the  region  of  the  stomach  reveals  the  existence  of  an  area 
of  diffuse  tenderness,  varying  in  severity  at  different  points,  one  is  warranted 
in  concluding  that  a  diffuse  gastritis,  or  perhaps  simply  a  dyspepsia,  is  present. 
When  the  ingestion  of  hot  or  stimulating  substances,  or  of  certain  articles  of 
food,  causes  pain,  and  when,  further,  this  pain  is  aggravated  by  palpation,  it  is 


520  AMERICAN   PRACTICE   OF   SURGERY. 

permissible  to  suspect  the  existence  of  a  gastric  ulcer.  If  such  an  ulcer  really 
exists,  it  ■u"ill  be  found  that  cool,  demulcent,  and  soothing  drinks  lessen  the  pain. 
Diffuse  pain  in  the  region  of  the  stomach,  and  pain  also  in  the  back,  are  symptoms 
of  which  patients  affected  with  cancer  of  the  stomach  sometimes  complain. 
Such  spontaneous  pains  are  less  common  in  cases  of  ulcer  of  the  stomach.  Finallj^, 
there  is  a  certain  number  of  cases  of  both  forms  of  disease  in  which  the  patient 
makes  no  complaint  whatever  of  pain. 

Lactic  acid  is  usually,  but  not  alwaj^s,  present  in  the  gastric  contents  of 
patients  affected  with  cancer  of  the  stomach. 

There  are  many  difficulties  in  the  way  of  determining,  by  means  of  percus- 
sion, the  boundary  lines  between  the  stomach  and  adjacent  organs.  When 
the  stomach  contains  a  watery  fluid  and  the  colon  gas,  or  vice  versa,  there  is  no 
special  difficulty  in  determining  the  topographical  relations  of  these  organs  to 
each  other.  In  the  case  of  a  distended  stomach  the  relative  positions  of  the 
greater  curvature  and  the  navel  furnish  a  simple  and  fairly  trustworthy  indica- 
tion of  the  size  of  the  organ.  There  is  one  condition,  however,  in  which  this 
guide  cannot  be  safely  followed;  I  refer  to  the  descent  of  the  stomach  without 
any  associated  enlargement.  Adhesions  of  the  stomach  to  adjacent  structures 
are  very  likely  to  diminish  the  area  which  the  organ  normally  occupies,  as  deter- 
mined by  percussion.  On  the  other  hand,  when  the  stomach  loses  some  of  its 
motor  power  and,  as  a  result,  is  distended,  the  dimensions  of  this  area  will  be 
increased. 

Auscultatory  percussion  intensifies  the  sounds  and  enables  the  diagnostician 
to  determine  with  greater  precision  the  outlines  of  distended  organs.  The 
changing  of  the  position  of  the  patient,  or  the  introducing  into  the  stomach  of  a 
soft  bougie,  often  adds  to  the  value  of  a  previous  estimate. 

Auscultation  enables  us  to  determine  the  presence  of  the  deglutition  sound 
of  oesophageal  obstruction,  as  already  stated  above,  and  of  the  splashing  sounds 
of  fluid  in  the  stomach  and  even  in  the  transverse  colon.  The  latter  may  be 
heard  upon  simple  palpation,  with  or  without  the  aid  of  a  stethoscope.  In  some 
instances  distinct  splashing  can  be  heard  at  a  distance  from  the  patient,  without 
the  aid  of  any  instrument.  AMien,  long  after  eating  or  drinking,  a  splashing 
sound  is  caused  by  vigorous  palpation,  dilatation  or  atony  or  displacement  of 
the  stomach  may  be  inferred. 

The  Stomach  Contents. — A  knowledge  of  the  various  test  meals  employed 
and  of  the  technique  of  lavage  is  essential  to  a  suitable  understanding  of  the 
diagnosis  and  treatment  of  diseases  of  the  stomach.  These  are  matters,  however, 
w^hich  belong  more  strictly  in  the  domain  of  medicine  than  in  that  of  surgery, 
and  we  will  therefore  say  but  very  little  here  on  the  subject.  Free  hydrochloric 
acid  with  no  lactic  acid  characterizes  the  products  of  normal  digestion.  Con- 
versel}^,  the  absence  of  hydrochloric  acid  suggests  the  possible  presence  of  a 
cancer  of  the  stomach,  while  the  presence  of  alkaline  or  offensive  vomiting 


GENERAL  SURGICAL  DIAGNOSIS.  521 

indicates  hemorrhage  from  the  stomach  and  fecal  invasion  of  the  organ.  The 
presence  of  bile  and  of  various  medicines  mixed  with  the  contents  of  the  stomach 
materially  changes  the  appearance  of  the  stomach  contents  in  health  and  in 
disease.  It  is  therefore  important  to  weigh  this  fact  carefully  before  final  con- 
clusions are  drawn.  The  presence  of  a  splashing  sound  in  the  stomach  may  be 
present  for  two  or  three  hours  after  the  taking  of  food,  especially  when  a  liberal 
amount  of  fluid  is  ingested  at  the  same  time.  When  the  splashing  is  heard  at 
a  later  period  than  this,  the  noise  suggests  obstructive  changes  in  the  stomach, 
loss  of  tone,  or  of  delayed  absorptive  powers.  The  presence  of  undigested  food 
in  the  stomach  six  or  seven  hours  after  ingestion  indicates  conclusively  an  ab- 
normal delay  in  the  gastric  digestive  process,  and  calls  for  a  careful  survey  of 
the  case.  In  this  connection  it  should  be  noted  that  vomited  and  regurgitated 
ingesta  present  distinctive  differences.  In  the  former,  disintegrated  muscular 
fibres  are  mingled  with  the  characteristic  stomach  contents ;  in  the  latter,  the 
fibres  are  intact  and  not  associated  with  gastric  matters. 

The  "stagnation  test" — i.e.,  the  determining,  by  the  stomach  tube,  that 
the  digestive  functions  of  the  organ  are  performed  more  slowly  than  they  should 
be — is  of  great  practical  utility. 

Mucus  is  freely  expelled  from  the  stomach  by  vomiting  in  cases  of  severe 
gastric  irritation  and  in  other  gastric  disorders,  and  often,  too,  it  is  mingled 
with  the  fluids  of  the  oesophagus  and  the  mouth.  The  employment  of  the  rec- 
ognized tests  for  saliva  and  for  mucus  is  essential  under  these  conditions. 

Blood  expelled  from  the  mouth  by  vomiting  may  have  come  from  the  stomach, 
the  oesophagus,  or  the  lungs,  or  from  the  mouth  or  its  accessory  cavities.  The 
source  from  which  it  originates  is  clearly  a  matter  of  great  importance.  Blood 
coming  from  the  stomach  is  expelled  by  vomiting,  and  is  mixed  at  first  with 
the  gastric  contents;  later,  if  the  stomach  has  been  emptied  and  if  nothing  has 
been  introduced  into  it  since  the  vomiting  occurred,  the  blood  will  be  found 
unmixed  with  food.  If  the  blood  be  abundant  and  if  it  be  promptly  expelled,  it  is 
florid;  but  if  it  be  meagre  in  amount  or  long  retained  in  the  organ,  or  swallowed, 
the  redness  is  not  marked,  and  the  matter  vomited  may  be  of  "coffee-ground" 
appearance.  When  bile  becomes  mixed,  in  the  stomach,  with  ingesta  of  various 
kinds  and  with  Epsom  salts  (administered  for  the  purpose  of  inducing  catharsis), 
there  is  produced  a  mass  which,  when  brought  to  view  by  the  act  of  vomiting, 
resembles  so  closely  partly  digested  blood  as  to  require  special  means  to  make  a 
clear  distinction  between  the  two.  In  cancer  of  the  stomach  hemorrhage  is 
comparatively  frequent,  but  rarely  profuse.  In  ulcer  of  the  organ  the  reverse 
of  these  manifestations  is  more  often  the  case.  The  destructive  blood  changes 
of  acute  or  chronic  disease,  the  traumatism  produced  by  external  violence  or 
by  vomiting,  and  the  engorgement  of  the  blood-vessels  due  to  portal  obstruction 
may  each  cause  hsematemesis  of  a  trivial  or  severe  character. 

Blood  from  the  oesophagus  is  usually  of  small  amount,  unless  it  be  due  to 


522  AMERICAN  PRACTICE  OF  SURGERY. 

rupture  of  an  aneurism,  it  is  expelled  by  regurgitation,  and  is  not  mixed  with 
the  stomach  contents  except  in  those  cases  in  which  it  may  have  been  swallowed 
and  afterward  expelled  by  vomiting.  The  fluids  of  the  mouth  and  the  cesopha- 
gus,  and  perhaps  the  secretions  of  the  bronchial  tubes,  may  be  mixed  together, 
provided  that  much  irritation  of  the  first  two  regions  has  been  present  or  that 
coughing  has  attended  the  escape  of  blood.  This  history  of  bleeding  from  the 
oesophagus  should  contraindicate  the  use  of  an  oesophageal  tube,  until  a  thorough 
examination  has  established  the  fact  that  the  patient's  need  is  greater  than  the 
danger  attending  the  emplo3auent  of  the  instrument.  The  presence  of  an 
aneurism  in  immediate  contact  with  the  oesophagus  should  be  especially  thought 
of  in  this  connection.  Blood  from  the  lungs  is  expelled  by  coughing,  as  a  rule, 
and  is  not  mixed  with  the  contents  of  the  stomach,  unless  vomiting  has  been 
provoked  by  severe  coughing  or  from  some  other  reason.  The  amount  and  color 
of  the  blood  vary  according  to  the  cause  of  the  hemorrhage  and  the  condition  of 
the  patient.  Bronchial  bleeding  may  be  noted  in  the  form  of  streaks  in  the 
mucus  expelled  by  coughing,  or  it  may  be  quite  profuse.  In  both  cases  the 
blood  will  have  a  florid  color.  When  the  blood  comes  from  pulmonary  tissues 
the  amomit  may  be  small  or  profuse,  florid  or  dark,  according  to  the  extent  to 
which  the  disease  has  invaded  the  arterial  or  the  venous  supply.  The  rupture 
of  an  aneurism  into  the  bronchus  suggests  the  escape  of  a  large  amount  of  blood, 
although  at  first  it  may  be  only  of  small  amount.  In  the  case  of  repeated  hemor- 
rhages the  amount  increases  rapidly.  Blood  from  the  mouth  may  originate 
from  either  of  the  sources  already  described,  and  be  detected  by  the  same  char- 
acteristics as  before  stated.  Blood  from  the  pharynx,  the  posterior  nares,  and 
other  parts  of  the  region  may  be  swallowed  in  considerable  amounts,  especially 
while  the  patient  is  in  the  recumbent  posture;  and,  if  it  be  expelled  by  vomiting, 
it  may  be  mistaken  for  gastric  hemorrhage — an  important  fact  in  fracture  of 
the  base  of  the  skull,  in  which  condition  it  is  quite  liable  to  occur  because  of  the 
semi-conscious  state  of  the  patient.  At  this  time  it  is  wise  to  remind  the  reader 
of  the  general  constitutional  effects  of  great  loss  of  blood  (shock),  and  also  of  the 
influences,  on  the  blood,  of  profuse  and  repeated  hemorrhages.  (Consult  the 
articles  on  these  subjects  in  the  present  volume.) 

The  Liver. — The  relation  of  the  liver  to  the  chest  wall,  the  diaphragm,  the 
peritoneum,  the  pleura,  the  intestines,  and  the  gall  Ijladder,  together  with  the 
modification  of  those  relations  incident  to  the  mobility  of  the  organ,  furnishes 
a  series  of  anatomical  facts  of  comprehensive  importance  in  relation  to  diagnosis. 
Briefly  expressed,  the  upper  limit  of  liver  dulness,  in  the  normal  state,  corre- 
sponds, in  the  mammillary,  midaxillary,  and  scapular  Ihies,  to  the  sixth,  eighth, 
and  tenth  ribs  respectively.  The  normal  width  of  liver  dulness,  in  the  mid- 
sternal,  the  mammillary,  the  midaxillary,  and  the  scapular  lines,  is  three  and 
three-fourths,  four,  six,  and  three  inches  respectively.  These  and  associated 
topographical  facts  afford  an  opportunity  of  estimating  the  degrees  of  change 


GENERAL  SURGICAL  DIAGNOSIS.  523 

in  the  general  and  circumscribed  modifications  of  the  area  of  fiver  dulness,  as 
caused  by  disease  either  of  that  organ  or  of  contiguous  organs.  Passive  conges- 
tion, amyloid  disease,  leuksemia,  hypertrophic  cirrhosis,  cancerous  infiltration, 
etc.,  furnish  illustrations  of  the  diseases  which  may  cause  a  general  increase  in 
the  size  of  the  liver;  atrophic  cirrhosis  and  acute  yellow  atrophy  affording  the 
best  examples  of  diseases  which  may  cause  a  diminution  of  the  size  of  the  organ. 

Circumscribed  modifications  of  liver  dulness  are  due  to  the  presence  of  ab- 
scess or  cancer  or  cyst,  and  to  such  deformities  as  floating  lobes,  Riedel's  lobe, 
and  tight-lacing  liver,  so  located  as  to  interrupt  the  normal  outline  of  liver  dul- 
ness. Other  factors  which  may  alter  the  area  of  liver  dulness  are  an  enlarged 
gall  bladder,  a  diaphragmatic  hernia,  a  rickety  thorax,  and  Pott's  disease  of  the 
spine.  Pulmonary  emphysema,  pleuritic  effusion,  an  intrathoracic  tumor,  and 
subphrenic  abscess  (between  liver  and  diaphragm)  are  among  the  diseases  that 
change  the  superior  outlines  of  liver  dulness  and  at  the  same  time  displace  that 
organ  downward.  On  the  other  hand,  the  liver  may  be  displaced  upward,  and 
the  outline  of  the  area  of  dulness  be  correspondingly  altered,  by  any  of  the  follow- 
ing pathological  conditions:  an  abdominal  tumor,  such  as  a  pancreatic  cyst  or 
a  cyst  of  some  other  organ;  abdominal  distention  from  the  presence  of  gas  in 
the  intestines  or  of  pus  or  other  fluid  in  the  peritoneal  cavity;  collapse  or  con- 
traction of  the  lungs;  and  paralysis  of  the  diaphragm.  Then,  again,  other 
areas  of  dulness — due,  for  example,  to  the  presence  of  an  accumulation  of  fteces 
in  the  colon  or  to  cancerous  or  tuberculous  disease  of  the  omentum  or  of  the 
posterior  aspect  of  the  kidney — may  become  blended  with  that  of  the  liver, 
and  thus  greatly  enhance  the  difficulty  of  making  a  diagnosis.  Finally,  it  must 
not  be  forgotten  that,  under  normal  conditions,  the  liver  is  moved  appreciably 
downward  by  the  diaphragm  with  each  full  inspiratory  act.  In  penetrating 
wounds  of  the  thorax,  it  is  important  to  know  that  the  dome  of  the  diaphragm 
corresponds  to  the  fourth  rib  on  the  right  and  to  the  fourth  interspace  on  the 
left  side  of  the  chest,  and  that  ordinary  respiration  alters  this  curve  but  slightly, 
-while  a  full  inspiration  makes  a  decided  change,  as  the  influence  on  the  line  of 
liver  dulness  will  disclose.  In  instances  of  perihepatitis  from  traumatisms  of 
various  kinds,  from  abscess,  and  from  inflammation  of  the  liver,  friction  sounds, 
tenderness,  and  even  enlargement  of  the  organ  may  be  found  on  physical  ex- 
amination. 

The  location  of  the  pleural  (costo-phrenic)  sinus  and  the  relation  of  the 
pleura  to  the  diaphragm,  and  of  the  liver  to  this  muscle  and  to  contiguous  vis- 
cera, are  each  of  much  significance.  Before  operating,  for  the  purpose  of  evac- 
uating an  abscess  of  the  posterior  portion  of  the  liver,  it  may  be  found  necessary 
to  obliterate  the  pleural  sinus;  the  purpose  of  this  preliminary  step  being  to 
prevent  infection  of  the  pleural  cavity.  On  the  other  hand,  it  is  sometimes 
found  that  this  obliteration  has  already  taken  place  through  the  action  of  an 
inflammation  of  recent  or  of  old  date.     The  obliteration  of  this  sinus  cripples 


524  AMERICAN  PRACTICE  OF  SLHIGERY. 

the  action  of  the  diaphragm.  The  diaphragmatic  pleura  and  the  opposing 
puhnonary  plem-a  may  miite  to  protect  the  lung  for  a  time  against  the  invasion 
of  sub-diaphragmatic  or  hepatic  abscess.  The  liver  may  be  safely  approached 
from  above  through  the  diaphragm  by  reflecting  upward  from  it  the  diaphrag- 
matic pleura.  Finally,  it  must  not  be  forgotten  that  the  relation  of  the  gall 
bladder  to  the  costal  end  of  the  ninth  (freely  movable)  rib,  and  the  presence 
there  of  the  lower  border  of  the  liver  in  health,  are  anatomical  facts  which  have 
an  important  bearing  upon  diagnosis. 

The  Intestines. — At  the  outset  one  ought  to  be  entirely  familiar  with  the 
topography  of  the  abdomen  and  its  contents  in  health:  otherwise, ■  even  marked 
abnormal  deviations  will  not  be  noted  and,  as  a  result,  their  significance  will 
not  be  appreciated.  A  reasonable  knowledge  of  the  anatomy  of  this  region 
enables  one  to  understand  why  it  is  that,  in  a  distended  colon,  the  distention 
is  well  marked  except  at  the  splenic  and  hepatic  flexures;  why  it  is  that  abdom- 
inal distention,  beginning  at  the  upper  or  the  lower  part  of  the  abdomen,  in- 
dicates, in  the  former  case,  distention  of  the  stomach  and  jejmium,  and,  in  the 
latter,  of  the  ileum  alone;  and,  finally,  why  it  is  that  a  special  tympanitic  en- 
largement at  the  right  iliac  fossa  tells  of  a  distended  csecum.  The  latter  fact 
is  often  of  great  importance,  indicating,  as  it  does,  at  which  side  (colonic  or 
enteric)  an  obstruction  exists,  and  often  causing  the  csecum  to  be  regarded 
as  the  "key"  to  the  seat  of  intestinal  obstraction.  The  relations  of  palpation 
and  percussion  to  the  presence  of  fluid  in  the  abdominal  cavity,  and  the  change 
in  the  positions  of  percussion  sounds  in  their  relations  to  one  another,  due  to 
changes  in  the  position  of  the  patient,  ought  to  be  kept  clearly  in  mind,  as  being 
important  diagnostic  facts.  '\^^ien  a  loop  of  small  intestine  is  in  a  distended 
state,  due  to  a  distal  obstruction  in  the  immediate  vicinity,  it  is  possible,  in  the 
case  of  a  person  with  thin  abdominal  walls,  to  excite  easily  visible  peristaltic 
mo^•ements  by  the  application  of  cold  to  the  abdomen. 

A  knowledge  of  the  anatomical  topography  of  the  abdomen  makes  it  pos- 
sible for  the  diagnostician  to  determine,  with  a  fair  degi'ee  of  accuracy,  what 
pathological  changes  are  taking  place  in  the  different  parts  of  the  imderl3^mg 
abdominal  cavity;  and  a  further  knowledge  of  the  relations  in  health  and  dis- 
ease between  the  gall  bladder  (distended)  and  the  kidney,  and  the  modifications 
which  respiratory  action  may  cause  in  these  relations,  furnishes  a  safe  basis 
upon  which  a  differential  diagnosis  may  be  constructed.  In  estimatuig  the 
size,  location,  and  degree  of  mobility  of  the  kidneys,  it  will  be  found  that  inspec- 
tion, percussion,  and  palpation  (mainly  bimanual),  in  combination  with  a  care- 
ful consideration  of  all  the  symptoms  and  an  examination  of  the  urine,  furnish 
us  with  the  only  means  of  arriving  at  the  truth. 

Investigations  in  this  field  are  very  difficult  to  carry  out,  and  require,  if 
successful  results  are  to  be  attamed,  considerable  skill  and  experience.  The 
same  remarks  apply  with  nearly  equal  force  to  the  spleen  and  to  other  organs 


GENERAL  SURGICAL  DIAGNOSIS.  525 

of  the  abdominal  cavity.  The  consideration  of  all  the  details  connected  with  the 
diagnosis  of  the  different  diseases  of  the  abdominal  organs  does  not  form  a  part 
of  the  writer's  purpose  in  preparing  the  present  article.  These  subjects  will 
all  be  fully  discussed  in  the  special  articles  which  are  to  appear  in  the  later 
volumes,  and  the  reader  is  therefore  referred  to  them  for  any  further  informa- 
tion which  he  may  desire. 

The  method  of  ascertaining  the  condition  of  the  contents  of  the  pelvis  by 
means  of  the  finger  introduced  into  the  rectum  or  the  vagina  is  one  of  the 
most  valuable  methods  of  diagnosis  that  we  possess.  By  it  we  are  enabled 
to  learn  the  presence  of  an  obstruction  in  the  intestinal  canal  and  to  form  a 
fairly  good  idea  of  its  nature — whether  a  new  growth  or  a  lesion  of  an  ulcera- 
tive nature.  It  is  also  possible,  by  the  same  procedure,  to  ascertain  the  exist- 
ence of  intestinal  prolapse,  or  the  presence,  at  or  near  the  brim  of  the  pelvis, 
of  an  offending  appendix  or  ovary,  of  an  abscess,  or  of  a  malignant  tumor 
springing  from  bone.  Finally,  this  method  of  exploration  enables  us  to  learn 
the  condition  of  the  bladder,  prostate,  etc.,  in  the  male,  and  that  of  the  uterus 
and  its  appendages  in  the  female.  Far  too  many  instances  of  irremedial  cancer 
of  the  rectum,  vagina,  and  uterus  come  to  light  in  consultation  practice  to 
warrant  the  belief  that  commendable  forethought  is  always  practised  by  the 
medical  attendant  first  in  the  field.  We  have  no  hesitation  in  asserting  that 
the  loss  of  life  and  the  great  misery  caused  by  these  afflictions  will  be  lessened 
decidedly  when  an  uiflexible  rule  is  adopted  of  examining  the  rectum,  the  va- 
gina, and  the  uterus,  when  practicable,  in  all  instances  in  which  advice  is  sought 
for  the  relief  of  ailments  of  these  or  of  contiguous  parts. 

Fffical  incontinence  owes  its  origin  to  localized  loss  of  power  of  the  sphincter 
muscle,  and  this  in  turn  may  be  due  to  a  variety  of  causes,  e.g.,  overdistention, 
relaxation,  incision,  rupture  of  the  perineum,  etc.  Pauiful  defecation,  with 
or  without  rectal  tenesmus,  comes  from  various  causes.  Among  them  may  be 
enumerated:  an  anal  fissure,  a  facal  mass,  an  inflamed  prostate,  a  rectal 
cancer,  and  an  inflamed  or  retroflexed  uterus.  Rectal  tenesmus  often  causes 
great  suffering,  and  it  is  especially  frequent  in  those  who  would  unwisely  en- 
deavor to  gain  relief  by  persistent  straining  at  stool.  Impacted  faeces,  foreign 
bodies  in  the  rectum,  prolapsed  hemorrhoids  or  prolapsed  mucous  membrane, 
cancer  of  the  rectum,  rectal  polypus,  dysentery  and  inflammation  of  the  bowel, 
and  intussusception  will  cause  more  or  less  tenesmus.  Rectal  tenesmus  is 
not  infrequently  associated  with  painful  defecation,  often  adding  much  suffer- 
ing and  prostration  to  an  already  painful  infliction.  Voluntary  resistance 
to  the  desire,  the  adoption  of  the  recumbent  posture,  and  prompt  exploration 
of  the  bowel  to  ascertain  the  presence  therein  of  an  exciting  cause  are  the 
measm-es  which  should  be  taken  for  the  relief  of  the  suffering. 

The  Stools. — The  frequency,  shape,  color,  consistence,  odor,  and  constit- 
uents of  the  stools  should  always  be  noted,  especially  in  cases  of  intra-ab- 


526  AMERICAN  PRACTICE  OF  SURGERY. 

dominal  injury  and  disease.  The  frequency  of  defecation  in  disease  and  in 
injury  should  be  compared  with  the  habit  of  the  patient  m  health,  due  allow- 
ance being  made  for  the  kind  and  quantity  of  food  which  he  eats  and  for  any 
medicaments  which  he  may  have  taken. 

The  size  and  shape  of  a  stool  are  regulated  by  the  amoimt  and  the  con- 
sistence of  the  faeces,  the  shape  and  size  of  the  canal,  and  the  degree  of  the 
force  of  expulsion.  A  small  round  stool  suggests  anal  prolapse  or  an  annular 
stricture  of  the  rectum,  and  it  may  attend  intussusception;  the  ribbon-shaped 
stool  indicates  the  presence  of  large  hemorrhoids,  an  enlarged  prostate,  or 
spasm  of  the  anus,  and  it  sometimes  attends  stricture  of  the  rectum.  The 
color  of  the  stools  is  modified  by  the  kind  of  food  ingested,  by  anything  that 
interferes  with  bile  formation  and  discharge,  by  medication,  etc.  Milk  and 
starchy  foods  predispose  to  light  yellow  stools:  dark-colored  fruits  and  fluids 
darken  the  stools,  changing  them  often  to  correspond  with  the  substances 
ingested:  interference  with  the  proper  discharge  or  with  the  formation  of  bile 
causes  light  or  clay-colored  stools,  according  to  the  degree  of  the  interference, 
and  suggests  the  presence  of  cholelithiasis,  cancer,  etc.,  or  structural  change 
in  the  liver,  pancreas,  or  duodenum.  The  green  stools  of  infancy  and  the  dark 
ones  of  any  age  indicate,  respectively,  bacteriologic  coloring  and  the  effects 
of  iron,  bismuth,  etc.,  medicinally  emploj^ed.  Red  and  tar-colored  stools 
indicate  the  presence  of  blood,  the  former  coming,  as  a  rule,  from  the  lower 
bowel,  especially  the  rectum.  If  the  stools  are  red  and  if  they  originate  from 
some  point  much  higher  up  than  this,  the  amount  of  the  blood  must,  at  the 
time  of  the  hemorrhage,  have  been  large  and  the  expulsion  rapid.  The  tarry 
stool  indicates  the  occurrence  of  hemorrhage  high  up  in  the  digestive  tract, 
or  in  the  upper  part  of  the  lower  bowel,  or  in  the  small  intestine,  or,  perhaps, 
even  in  the  stomach;  or  it  may  indicate  slow  expulsion  of  the  intestinal  contents, 
and  also  the  influence  of  the  digestive  process  on  the  blood  that  has  escaped 
into  the  intestinal  canal.  Microscopical  or  chemical  and  spectrum  examina- 
tions may  be  needed  clearly  to  establish  the  presence  of  blood  in  a  stool.  The 
consistence  or  density  of  a  stool  is  often  a  matter  of  much  surgical  significance, 
as  related  to  the  presence  of  impacted  faeces  causing  diarrhoea,  as  indicating 
the  degree  of  intestinal  constriction  consistent  with  the  passage  of  a  stool  of 
a  given  diameter,  as  denotmg  in  a  degree  the  amount  of  the  discharge  attend- 
ing an  ulcerative  process  m  the  intestine  or  the  escape,  into  the  gut,  of  the 
contents  of  a  contiguous  abscess  or  cyst.  Scybalous  masses  passed  with  or 
without  the  aid  of  enemata  are  often  of  important  significance  as  related  to 
intestinal  obstruction  and  to  medication.  The  naturally  offensive  odor  of  a 
stool  is  increased  to  near  the  line  of  putridity  by  the  diminution  or  absence 
of  bile  in  the  intestine,  as  in  obstructive  disease  of  the  gall  ducts,  in  specific 
or  malignant  ulceration  of  the  intestine,  and  in  the  gangrenous  processes  of 
dysentery.     Long-retained,   unabsorbed    nutritive    enemata    not    infrequently 


GENERAL  SURGICAL  DIAGNOSIS.  527 

lead  to  highly  offensive  stools.  In  suspected  intestinal  obstruction  the  escape 
of  unusually  offensive  flatus  is  often  happily  followed  by  a  reassuringly  copious 
stool. 

A  stool  in  the  normal  state  is  composed  almost  entirely  of  the  products 
of  the  digestive  tract  and  the  associated  organs,  and  of  those  portions  of  the 
food  which  cannot  be  digested.  Morbid  processes,  however,  may  increase 
the  amount  of  mucus  and  even  stain  it  with  blood,  as  in  inflammations  of 
the  mucous  membrane  of  the  intestine  and  in  intussusception.  Sloughing 
mucous  membrane  may  add  to  the  stool  membranous  shreds;  disease  of  the 
pancreas  due  to  injury  or  to  a  calculous  obstruction  may  add  fat;  gall  stones, 
too,  are  sometimes  found  in  it,  and  they  may  be  of  such  a  size  as  to  cause  com- 
plete intestinal  obstruction.  Pus,  foreign  bodies,  and  various  kinds  of  para- 
sites also  invite  attention  in  special  instances. 

The  Respiratory  System.— The  careful  study  of  the  topography  of  the 
thorax,  when  it  is  in  an  active  as  well  as  when  it  is  in  a  quiescent  state,  a  thor- 
ough knowledge  of  the  means  of  making  a  physical  examination  of  the  chest 
and  of  the  signs  elicited  by  such  an  examination,  along  with  an  understanding 
of  the  normal  and  abnormal  rhythm  of  respiration,  constitute  the  minimum 
of  knowledge  requisite  for  an  intelligent  appreciation  of  the  common  respiratory 
phenomena  of  injury  and  disease. 

It  is  important  for  the  surgeon  to  note,  not  only  the  limits  of  the  pleural 
cavities  in  health  and  in  disease,  but  also  the  relation  of  the  lungs  to  the  pleura 
and  to  the  chest  walls;  otherwise  he  may  imperil  the  patient's  chances  by  a 
needless  invasion  of  a  pleural  cavity  or  of  the  lungs.  Since  these  relations 
are  much  changed  by  the  deep  respiratory  act,  the  importance  of  making  an 
incision  into  the  pleural  cavity  midway  during  an  inspiration  or  an  expiration 
ought  to  be  apparent.  That  the  pleura  in  health  extends  in  the  mammil- 
lary,  the  midaxillary,  and  scapular  lines  about  two,  three  and  one-third,  and 
one  and  one-half  inches,  respectively,  lower  than  the  corresponding  borders  of 
the  lungs  is  a  matter  of  much  practical  significance  in  thoracic  operations 
and  in  abdominal  operations  related  to  the  lower  border  of  the  ribs  (see  remarks 
on  p.  523  with  regard  to  the  area  of  liver  dulness).  The  important  points 
in  chest  topography,  so  far  as  it  relates  to  diagnosis,  are  the  following:  the 
clavicle  corresponds  to  the  first  rib;  the  projection  at  the  junction  of  the  first 
and  second  pieces  of  the  sternum  corresponds  to  the  second  rib;  the  nipple, 
in  the  male,  corresponds  to  the  fourth  intercostal  space;  a  line  passed  over 
the  nipple  around  the  chest  crosses  the  sixth  interspace  at  the  axillary  line 
(important  in  tapping  the  chest);  the  cartilage  of  the  seventh  rib  and  the 
ensiform  process  form  an  epigastric  angle;  the  cartUage  of  the  ninth  rib  corre- 
sponds to  the  gall  bladder;  and  the  eleventh  and  twelfth  ribs  can  be  located 
outside  the  erector  spinas  in  stout  persons. 

Inspection. — The  inspection  of  the  chest  in  health  and  in  disease,  if  intelligently 


528  AMERICAN  PRACTICE  OF  SURGERY. 

conducted,  is  of  great  significance.  Ordinary  inspection  may  be  supplemented 
with  advantage  by  the  use  of  the  x-ray.  One  should  note  the  frequency,  the 
type,  the  character,  and  the  rhythm  of  the  respiratory  acts.  It  is  also  impor- 
tant to  observe  whether  or  not  the  normal  costal  breathing  is  modified  by  the 
presence  of  disease  or  injury  of  the  pleura,  the  lungs,  or  the  diaphragm,  or  by 
disease  of  the  abdomen  from  any  cause;  whether  or  not  the  diaphragmatic 
type  is  changed  from  the  normal  by  pleurisy,  pleurodynia,  intercostal  neu- 
ralgia, peritonitis,  paral3'sis  or  spasm  of  the  abdominal  muscles,  fracture  of  a 
rib,  etc.  Nearly  all  forms  of  disease  increase  the  frequency  of  the  respiratory 
act.  Narcotic  poisoning  and  disease  or  traumatism  of  the  respiratory 
centre  lessen  the  frequency  of  respiration.  Cerebral  compression  changes  the 
character  of  respiration,  which  becomes  stertorous. 

Significance  of  the  Changes  in  the  Character  and  Rhythm  of  the  Respiratory 
Acts. — Increased  inspiratory  effort  points  to  an  obstruction  to  the  entrance 
of  air,  dependent  on  an  impediment  in  the  larynx  or  trachea;  a^lema  of  the 
glottis  and  pressure  from  an  aneurism  upon  the  trachea  are  the  two  patho- 
logical conditions  which  ought  to  be  thought  of  in  this  connection.  This  kind 
of  obstructed  inspiration  is  attended  by  increased  expansion  of  the  subcla- 
vicular regions  and  by  retraction  of  the  supraclavicular  and  intercostal  spaces, 
and  of  the  epigastric  area.  Labored  expiratory  effort  is  attended  with  bulg- 
ing of  the  intercostal  spaces;  emphysema  and  asthma  being  the  common 
causes.  In  the  former  disease  bulging  of  the  soft  parts  above  the  clavicle 
may  be  observed  during  inspiration.  The  modifications  in  rhythm  include 
the  Cheyne-Stokes  respiration  and  the  sensory  and  pupillary  phenomena  so 
often  associated  therewith.  This  form  of  respiration  is  noted  especially  in 
grave  cardiac,  renal,  and  cerebral  disease  and  as  a  result  of  certain  injuries; 
and  it  is  sometimes  observed  in  the  typhoid  and  septic  states  associated  with 
pneumonia  and  the  eruptive  fevers.  The  jerking  respiration  of  acute  pain 
in  the  chest,  as  in  fracture  of  a  rib,  the  snoring  breathing  of  the  coma  of  disease 
and  of  narcotic  poisoning,  and  the  noisy  respiration  of  faucial  obstruction 
or  paralysis  are  familiar  phenomena  and  aptly  illustrate  modifications  in  re- 
spiratory rhythm. 

The  uniformity  of  expansion  of  the  chest  attendant  on  normal  respiration 
is  modified  in  a  striking  degree  by  disease  and  by  excitement.  Dyspnoea  de- 
pendent upon  some  cause  or  other  may  be  associated  with  a  chest  which  remains 
of  the  same  degree  of  expansion  during  both  inspiration  and  expiration.  Men- 
tal excitement  and  physical  effort  are  each  capable  of  producing  the  same  effect. 
Usually,  however,  such  a  condition  of  things  suggests  the  existence  of  actual 
disease,  as,  for  example:  some  lesion  that  interferes  with  the  proper  entrance 
of  air  into  the  lungs;  a  loss  of  respiratory  power;  a  traumatism  of  such  a  nature 
that  the  patient  voluntarily  fixes  his  chest  in  order  thereby  to  escape  pain; 
acute  disease  involving  both  sides  of  the  chest.     Deviations  confined  to  one 


GENERAL  SURGICAL  DIAGNOSIS.  529 

side  of  the  chest  usually  imply  disease  or  injury  of  its  bony  framework,  and 
the  lack  of  mobility  of  the  affected  side  is  commonly  emphasized  by  the  greater 
mobility  of  the  sound  one,  which  is  performing  compensatory  work.  Defor- 
mity of  the  thorax  may  be  partial  or  general  in  extent,  of  transient  or  permanent 
tenure,  of  trivial  or  serious  aspect,  and  easy  or  impossible  of  correction. 

Various  instruments  are  employed  for  determining  the  dimensions,  the 
respiratory  capacity,  the  mobility,  and  the  surface  outlines  of  the  chest.  In- 
formation with  regard  to  these,  however,  cannot  properly  be  given  here;  the 
reader  must  seek  for  it  in  the  special  articles. 

In  a  general  survey  of  a  patient's  chest  it  is  desirable  to  note  carefully  the 
condition  of  the  surface  circulation.  In  a  normal  state  the  superficial  veins 
are  not  especially  noticeable,  but  they  may  become  so  enlarged,  through  the 
influence  of  some  disease  which  interferes  with  the  circulation  within  the  thorax, 
that  their  tortuous  outlines  are  plainly  visible.  In  a  case  of  long  standing, 
which  recently  came  under  my  observation,  the  patient's  face,  ears,  eyes, 
tongue,  and  throat  were  so  engorged  as  to  give  him,  for  a  time,  until  the  obstructed 
circulation  had  regained  its  equilibrium,  a  distorted  mien.  It  was  found  that 
the  obstruction  existed  in  the  interior  vena  cava  at  a  point  located  just  above 
the  heart.  As  a  result  of  this  obstruction  the  capillaries  and  veins  corresponding 
to  the  attachment  of  the  diaphragm  to  the  thorax  were  much  enlarged,  and 
became  rapidly  and  enormously  distended  because  of  a  temporary  increase 
in  the  obstruction;  and  as  a  further  result  there  was  venous  engorgement  of 
the  structures  of  the  body  which  empty  their  blood  into  the  channels  of  return 
circulation  above  the  diaphragm. 

It  will  not  be  amiss  at  this  time  to  direct  attention  to  the  following  anatom- 
ical facts  which  have  an  important  bearing  upon  the  question  of -diagnosis : 

Litten's  Diaphragm  Phenomenon. — This  manifestation  of  diaphragm  action 
occurs  in  thin  persons,  and  is  best  seen  by  placing  the  patient  on  the  back  in 
a  good  light  and  inspecting  the  chest  at  an  angle  of  fortj^-five  degrees.  It 
consists  of  a  shadowy  line  which  lies  at  an  acute  angle  to  the  ribs  and  travels 
downward  a  distance  not  exceeding  two  and  one-half  inches  (in  forced  inspira- 
tion) in  harmony  with  the  downward  movement  of  the  diaphragm.  The  mani- 
festation is  seen  to  begin  at  the  sixth  interspace  on  both  sides  with  inspiration, 
and  to  move  downward  to  the  free  borders  of  the  ribs  as  the  inspiratory  act 
is  completed.  In  expiration  the  reverse  of  the  movement  is  noted.  The  vital 
capacity  of  the  lungs  is  thought  to  be  proportionate  to  the  width  of  the  shadow. 
Eliot  has  called  attention  to  the  increased  depth  and  the  fixity  of  the  costal 
arch  in  the  presence  of  disease  of  the  contiguous  viscera.  Normally,  the  arch 
is  mobile  and  quite  easily  encroached  upon  by  pressure  against  the  lower  ribs. 
In  disease,  however,  it  is  wide  and  faxed.  Harrison  has  described  a  groove  that 
appears  on  the  chest  of  rickety  subjects  and  is  associated  with  impeded  inspira- 
tion due  to  obstruction  of  the  nose,  fauces,  and  bronchial  tubes,  from  various 


530  AMERICAN  PRACTICE  OF  SURGERY. 

causes.  This  grooved  line  begins  at  the  xiphoid  cartilage,  and  extends  along 
the  arched  surface  of  the  thorax  to  the  axilla  on  either  side. 

The  Circulatory  System.— T/ze  Heart. — The  established  position  of  the 
heart  in  the  chest  in  health  and  the  ordinary  phenomena  attending  its  activities 
are  matters  of  such  common  knowledge  as  fortunately  to  recjuire  no  special 
mention  here.  The  apex  in  health  in  the  adult  is  noted  in  the  fifth  intercostal 
space,  just  inside  the  mammillary  line.  Prior  to  the  tenth  or  twelfth  year  the 
apex  beat  is  in  the  fourth  intercostal  space,  at  or  just  outside  the  mammillary 
line.  In  making  these  observations  it  is  essential  to  note  if  the  nipple  is  dis- 
placed from  the  normal  site;  also  to  remember  that  changes  of  position  in 
health  are  attended  with  change  in  the  site  of  the  apex  beat.  If  the  body  be 
inclined  to  the  left,  the  apex  beat  approximates  the  midaxillary  Ime;  with  a 
full  inspiration  it  is  moved  downward  and  to  the  right.  In  old  age  the  apex 
beat  is  depressed,  and  in  transposed  viscera  the  change  in  the  site  of  the 
beat  is  correspondingly  modified.  Deformities  of  the  chest  incident  to  spinal 
disease  or  to  some  other  cause  change  the  relations  of  the  heart-beat  to  the 
chest  wall.  Diseases  of  neighboring  viscera,  characterized  by  the  pushmg  in- 
fluence of  fluids,  gases,  solid  and  aneurismal  tiunors,  etc.,  and  by  the  pulling 
effects  of  contracting  organs  and  adhesions,  aided  or  not  by  abdominal  disten- 
tion, often  change  the  position  of  the  entire  organ  to  a  degree  comparable  with 
the  extent  and  activity  of  the  morbid  process.  Hydrothorax,  pneumothorax, 
tumors  and  phthisis  of  the  pulmonary  tissue,  aneurism  of  the  aorta  or  of  the 
contiguous  vessels,  and  abdominal  distention,  encroaching  on  the  diaphragm, 
are  some  of  the  pathological  conditions  which  may  produce  a  displacement  of 
the  heart.-  Hypertrophy,  dilatation,  and  aneurism  of  this  organ,  and  peri- 
cardial-effusion  increase  and  change  the  area  of  cardiac  dulness  in  accordance 
with  the  degree  and  direction  of  the  modifying  process.  In  children  with 
rickets  or  with  marked  hypertrophy  or  dilatation  of  the  heart,  or  with  peri- 
cardial effusion  or  aneurism  of  the  heart,  the  precordial  region  may  be  bulging. 

Thrills  and  friction  sounds  are  appreciated  by  the  hand,  the  tremors  corre- 
sponding to  the  sites  of  the  valves  of  the  heart  and  the  direction  of  the  blood 
flow.  ;  Aneurism  of  this  organ  also  gives  to  the  hand  of  the  examiner  the  char- 
acteristic thrill.  The  friction  sound  of  pericarditis,  traumatic  or  otherwise, 
is  often  readily  distinguished  by  means  of  palpation;  auscultation  announces 
the  absence  or  feebleness  of  heart  sounds,  their  location,  rhythm,  the  seat  of 
greatest  intensity,  also  the  presence  of  abnormal  action,  enabling  one  to  judge 
of  the  need  of  treatment  and  of  the  value  of  the  remedial  measures  employed, 
especially  on  urgent  occasions. 

The  heart  sounds  are  intensified  by  a  variety  of  causes,  e.g.:  approximation 
of  the  organ  to  the  ear,  as  may  be  effected  by  pressure  from  the  outside;  thin- 
ness of  the  thoracic  wall;  hypertrophy  and  increased  action  of  the  heart;  up- 
ward pressure  upon  it  by  tumors;  pericardial  adhesions,  etc.     The  heart  sounds 


GENERAL  SURGICAL  DIAGNOSIS.  531 

are  diminished  by  conditions  diverse  from  those  just  preceding,  such  as,  e.g., 
a  thick  chest  wall,  distention  of  the  lung  or  of  the  pericardium  with  blood,  pus, 
or  air,  and  weakened  heart  action  from  any  cause.  The  splashing  sound  heard 
on  auscultation  indicates  the  presence  of  air  and  fluid  in  the  pericardium.  All 
of  the  foregoing  are  of  importance  in  cases  of  traumatism  of  the  heart.  The 
significance  of  the  various  murmurs,  etc.,  may  best  be  considered  in  books 
and  articles  devoted  to  the  purpose.  The  duskiness  of  the  surface  of  the  skin 
attending  general  obstruction  of  the  circulation,  and  the  paleness  from  feeble  or 
depleted  blood  supply,  need  only  be  mentioned  to  establish  their  significance. 

The  Vessels. — The  pulsation  and  enlargement  of  the  large  arteries  of  the 
extremities  and  neck  are  a  part  of  the  history  of  old  age,  cardiac  hypertrophy, 
excessive  physical  exercise,  excitement,  etc.  These  phenomena,  when  observed 
in  the  neck,  signify  aneurism  of  the  aorta,  atheroma.  Graves'  disease,  etc. 
Undue  enlargement  of  the  carotids  and  of  the  innominate,  in  such  cases,  is 
sometimes  mistaken  for  aneurism.  Pulsation  of  the  abdominal  aorta  in  thin, 
nervous,  or  apprehensive  subjects  is  frequently  the  cause  of  much  distress, 
and  may  be  mistaken  for  aneurism,  especially  when  associated  with  pain,  enlarged 
pancreas,  or  a  tumor  of  the  stomach,  omnetum,  or  colon.  The  epigastric 
pulsation  which  is  often  observed  in  these  cases,  or  which  may  be  transmitted 
from  above  by  a  hypertrophied  heart  directly,'  or  by  contact  with  the  liver, 
is  also  often  a  source  of  needless  solicitude  to  the  patient  and  possibly  to  the 
medical  attendant.  However,  in  all  these  cases  a  careful  differentiation  of 
the  phenomena  observed  from  those  which  attend  a  case  of  genuine  aneurism 
ought  soon  to  clear  up  all  doubts.  And  in  this  connection  it  is  well  to  examine 
the  smaller  arteries,  with  the  idea  of  noting  their  shape,  size,  and  pulsation 
as  related  to  arterio-sclerosis. 

Of  much  significance  are  the  pathological  changes  to  which  the  veins  are 
liable.  A  sudden  pain  in  the  calf  of  the  leg  or  in  the  instep,  the  tenderness 
and  hardness  in  the  course  of  the  femoral  or  iliac  vein,  followed  by  swelling 
of  the  leg  and  foot,  are  so  commonly  an  important  part  of  the  history  of  crural 
phlebitis  as  to  require  no  more  than  mention  at  this  time,  unless  it  be  to  warn 
agamst  the  possibility  of  mistaking  it  for  rheumatism,  as  is  frequently  done. 
In  ligaturing  a  distended  vein,  in  a  case  of  varicose  veins  of  the  lower  extremity, 
it  has  sometimes  happened  that  the  ligature  has  included  a  contiguous  impor- 
tant nerve,  thus  greatly  aggravating  the  original  pain  due  to  the  distention 
of  the  vessels.  The  surgeon,  therefore,  needs  to  be  on  his  guard  against  this 
accident.  Wlien  the  veins  of  the  arm  or  the  leg  become  gorged  with  blood 
and  the  skin  of  the  affected  limb  takes  on  a  dusky  hue ;  and  when,  furthermore, 
these  changes  are  soon  followed  by  the  development  of  oedema  and  pain  in 
the  parts  involved,  we  may  unhesitatingly  assume  either  that  a  thrombosis 
has  occurred  in  the  chief  vein  or  that  it  is  being  pressed  upon  by  some  patholog- 
ical product  at  a  point  in  or  not  far  distant  from  the  axilla  (in  the  case  of  the 


532  AilERICAX  PRACTICE   OF  SURGERY. 

arm)  or  the  groin  (in  the  case  of  the  leg).  For  example,  a  cancerous  growth  in 
the  axilla  or  in  the  pelvis  is  a  common  cause  of  such  a  sequence  of  events. 
In  this  connection  it  should  be  said  that  the  pressure  of  a  tumor  of  the  medias- 
tinum or  lung,  or  of  an  aneurism  of  the  arch  of  the  aorta,  or  of  the  subclavian, 
the  axillary,  or  the  innominate  artery  (right  side),  or  pressure  from  enlarged 
axillary  lymph  nodes,  may  each  be  followed  by  discoloration  and  cEdema 
of  the  corresponding  extremity.  It  must  not  be  forgotten,  however,  that  the 
free  clearing  out  of  the  contents  of  the  axilla  for  cancer  may  be  followed  by 
painful  and  excessive  oedema,  because  of  the  resulting  destruction  of  lymphatics 
— changes  which  may  be  confused  with  oedema  from  pressure  of  lymph-node 
involvement  attendant  on  a  relapse  of  a  maligiiant  growth.  Enlargements 
of  h-mph  nodes  and  morbid  growths  pressing  on  the  iliac  veins  of  either  side 
cause  cedema  and  pain  of  a  lower  extremity.  Finally,  there  remains  the  pos- 
sibility that  the  oedema  may  be  due  to  other  and  general  causes. 

The  enlargement  of  the  superficial  abdominal  veins,  taken  in  connection 
with  the  fact  that  the  l^lood  in  them  courses  in  the  reverse  direction,  indicates 
the  existence  of  some  obstruction  to  the  portal  circulation.  (See  also  the 
instance  of  obstructed  circulation  in  the  superior  vena  cava  referred  to  on 
p.  529.)  The  veins  of  the  mucous  surfaces  are  not  infrequenth'  dilated,  because 
of  portal  obstruction  and  of  the  hindrance  of  the  circulation  incident  to  arterio- 
sclerosis. The  hemorrhoidal  and  the  spermatic  veins  and  those  of  the  broad 
ligament,  etc.,  sustain  special  inflictions  of  a  varicose  nature,  which  may  be 
mistaken  for  disease  or  other  morbid  processes  of  these  regions.  The  ^'eins  of 
the  neck  are  large  and  cjuite  superficial,  and  the  varying  conditions  serve  as 
an  important  index  of  many  conditions.  For  example,  a  collapsed  jugular 
indicates  thrombosis  of  the  lateral  sinus,  especially  when  pressure  on  the  vein 
above  the  clavicle  is  not  followed  bj'  distention  of  the  vein.  Distention  of 
the  jugulai's  attends  coughing  and  straining  efforts  in  health.  Obstructed 
pulmonar}-  circulation  and  obstruction  to  A-enous  return  from  pressure  on 
the  innominate  and  other  deep  veins  of  the  neck  and  chest,  as  from  tumors 
and  aneurism,  cause  free  engorgement  of  the  veins  of  the  neck.  The  indistinct 
influence  of  an  inspirator}-  effort  on  the  jugulars  m  health  is  rendered  more 
distinct  when  these  vessels  are  engorged  from  any  morbid  cause.  Pulsation  of 
the  jugulars  may  be  transmitted  from  the  contiguous  carotids,  or  it  may  be 
due  to  obstruction  of  the  return  flow,  as  in  the  case  of  an  intrathoracic  tumor 
or  aneurism,  in  mitral  regurgitation,  in  interference  with  the  pulmonary  cir- 
culation from  anj'  decided  cause,  and  in  increased  intrarenal  pressure.  The 
valve  at  the  bulb  (junction  of  subclavian  vein  with  the  jugular)  conmionly 
arrests  the  upward  flow,  but  m  long-standing  or  decided  obstruction  dilatation 
of  the  ^•ein  follows,  and  this  impairs  or  destroj's  the  usefulness  of  the  valve  in 
preventing  a  return  flow.  Murmurs  are  sometimes  heard  in  veins;  they  are 
usuallv  of  anaemic  origin. 


GENERAL  SURGICAL  DIAGNOSIS.  533 

The  pulse  is  interrogated  to  determine  the  force,  frequency,  and  rhythm  of 
the  action  of  the  heart  and  the  degree  of  tension  of  the  arteries.  The  pulse 
should,  in  every  instance,  be  taken  under  conditions  which  are,  as  nearly  as 
possible,  alike;  and,  when  it  is  practicable  to  do  so,  the  test  should  be  made 
at  established  inter^'als.  A  change  in  position  of  the  patient,  excitement  of 
any  kmd,  active  digestion,  the  time  of  day,  etc.,  are  each  of  important  moment 
in  estimating  the  proper  significance  of  the  heart's  action  and  the  state  of  the 
pulse.  A  full  minute  of  estimate  of  the  pulse  is  better  than  a  fractional  esti- 
mate nmltiplied  to  equal  the  count  of  a  minute."  The  latter  practice  is  apt 
to  increase  the  numerical  record  in  proportion  to  the  smallness  of  the  fraction 
of  the  minute,  especially  when  a  full  measure  of  the  fractional  count  is  the 
multiplicand. 

In  taking  the  pulse  it  is  well  to  test  the  radial  arteries  of  both  sides,  espe- 
cially when  the  patient  shows  signs  of  prostration ;  for  an  unusually  small  vessel 
of  one  side  may  mislead  the  surgeon  in  properly  estimating  the  patient's  con- 
dition. The  temporal,  femoral,  or  carotid  vessels  may  be  selected  for  estimat- 
ing the  pulse  when  for  any  reason  the  radial  at  the  wrist  is  not  available,  but 
at  the  same  time  it  must  be  remembered  that  the  nearer  to  the  heart  and  the 
larger  the  vessel  the  more  pronounced  is  the  action.  The  slow  and  feeble  pulse 
of  cerebral  compression,  the  rapid  and  feeble  one  of  cerebral  and  other  kinds 
of  shock,  and  the  diminished  frequency  (bradycardia)  of  pulsation  in  increased 
arterial  resistance,  in  arterial  sclerosis  of  the  medulla,  in  Bright's  disease,  in 
bile  poisoning,  in  aneurism  of  the  heart,  in  convalescence  from  acute  disease 
and  depressing  injury,  etc.,  are  not  infrequent  exhibits  of  the  heart's  action 
under  these  varying  conditions.  The  increased  rate  (tachycardia)  of  pulsa- 
tion in  Graves'  disease,  in  the  abuse  of  the  use  of  narcotics,  in  excessive  sexual 
indulgence,  in  neurotic  states,  in  loss  of  blood,  etc.,  is  of  significant  import. 
The  pulse  beat  in  children  is  naturally  and  markedly  of  greater  frequency  than 
in  adults. 

Blood  pressure  is  a  matter  of  importance  and  can  be  sufficiently  well  esti- 
mated by  one  who  is  experienced  in  the  taking  of  the  pulse.  The  information 
gained  in  this  way  can  be  promptly  utilized  in  estimating  the  degree  of  shock 
or  the  amount  of  loss  of  blood  in  a  particular  instance.  Ordinary  experience 
determines  the  presence  of  the  hard,  wiry  pulse  of  acute  peritonitis.  However, 
the  employment  of  special  instruments  for  the  purpose  of  scientifically  record- 
ing the  blood  pressure  is  much  the  better  and  more  reliable  plan.  The  various 
examples  of  sphygmographs  and  sphygmomanometers  are  to  be  found  in  the 
article  on  Blood  Pressure  in  Surgical  Conditions. 

The  Temperature. — The  technique  of  taking  the  temperature  is  of  such 
common  knowledge  as  to  call  for  no  mention  here.  A  well-tested  and  reliable 
thermometer  should  be  employed  at  all  times.  Whether  or  not  the  mouth, 
the  axilla,  the  rectum,  or  the  vagina  be  selected  as   the  proper  site  will  depend 


534  AMERICAN  PRACTICE   OF  SURGERY. 

on  the  circumstances  of  the  case.  A  sense  of  dehcacy  may  render  it  inadvisable 
to  use  for  this  purpose  the  vagina  or  the  rectum;  a  sense  of  expediency  may 
make  us  hesitate  about  using  the  mouth,  especially  in  the  imaginative,  the 
young,  and  those  not  in  proper  control;  but  the  demands  of  accuracy  will 
approve  of  the  selection  of  whichever  place  will  furnish  us  with  the  most  trust- 
worthy results.  In  any  event  it  will  readily  be  admitted  that  it  is  always  wise 
to  cause  the  instrument  to  be  cleansed  in  the  presence  of  the  patient  before 
using.  Care  should  be  exercised  in  all  instances  in  taking  the  temperature  and 
in  recording  the  results.  When  efforts  at  deception  are  suspected,  only  vigi- 
lant and  protracted  observation,  amounting  to  keen  surveillance,  will  defeat 
the  purpose  of  those  who  are  interested  in  the  endeavor  to  deceive.  In  esti- 
mating the  importance  of  the  temperature  record  in  disease  it  is  well  to  recall 
that  the  normal  temperature  of  the  rectum  and  vagina  is  higher  than  that  of 
the  mouth,  and  is  less  liable  to  accidental  variations;  on  the  other  hand,  the 
temperature  of  the  axilla  is  almost  a  degree  lower  than  that  of  either  of  the 
mucous  channels  already  mentioned,  and  only  with  comparatively  great  care 
can  a  correct  record  be  made  in  this  locality.  Normally,  the  temperature  of 
the  body  is  highest  during  the  daj'time,  and  is  lowest  at  from  two  to  four  in  the 
morning — facts  which  are  to  be  considered  in  estimating  the  fluctuation  of 
the  temperature  in  disease  at  the  time  mentioned.  The  frequency  of  taking 
the  temperature  is  a  matter  both  of  custom  and  of  demand.  The  intervals  of 
custom  are  a  matter  of  choice — once  in  three  or  four  hours,  when  practicable. 
When  the  circumstances  of  a  case  demand  the  adoption  of  a  certain  interval 
we  must  conform  to  the  needs  of  the  case.  In  any  instance  neither  over-anxiety 
nor  exceeding  diligence  should  be  permitted  to  measure  the  interval.  Physio- 
logically, youth,  exercise,  digestion,  excitement,  and  heated  environment 
increase  the  temperature.  Old  age,  cold,  and  depressing  influences  lower  it. 
The  normal  temperature  is  98.6°  F. ;  but  shock,  loss  of  blood,  starvation,  wast- 
ing disease,  cerebral  abscess  (often),  myxcedema,  and  great  prostration  are 
attended  with  a  subnormal  temperature  (97°  F.).  Sometimes  a  sudden  drop 
to  94°  F.  or  less  attends  the  intermittent  manifestations  of  pyaemia,  with  abscess 
complications,  and  of  the  liver  infections.  High  temperatures  of  such  romantic 
altitudes  as  150°  F.,  more  or  less,  need  not  be  considered  seriously  in  connec- 
tion with  the  morbid  processes  of  physical  disease.  One  of  122°  F.  appears 
to  be  entitled  to  respectful  consideration.  Personallj^,  I  have  not  yet  observed 
a  temperature  above  110°  F. — once  in  a  case  of  hysteria  (probably  deceptive); 
several  times  in  cervical  injury  involving  the  spinal  cord,  soon  followed  by 
death  of  the  patients;  and  once  in  insolation,  also  followed  by  death. 

The  giving  of  the  coal-tar  products  in  advance  of  a  diagnosis  of  the  cause  of 
the  fever,  for  the  purpose  of  reducing  the  temperature,  is  an  error  often  com- 
mitted, and  always  invests  the  case  with  an  element  of  needless  uncertainty 
that  should  be  avoided. 


GENERAL  SURGICAL  DIAGNOSIS.  535 

The  relation  of  a  patient's  body  temperature  to  the  time  of  operation  is  a 
matter  of  decided  significance.  A  fever  (100°  to  103°  F.)  developing  within  the 
first  twenty-four  hours  after  an  operation,  attended  with  no  obvious  symptoms, 
and  disappearing  within  three  or  four  days,  is  characterized  as  an  "aseptic 
fever"  or  as  "post-operative  fever,"  and  is  due  to  the  presence  in  the  blood  of 
irritating  products  (nucleins,  etc.)  resulting  from  the  injury.  Wlien,  however, 
the  body  temperature  remains  elevated  for  three  or  four  days,  and  other  symp- 
toms appear,  or  if,  after  becoming  normal,  the  temperature  again  rises,  the 
woimd  should  be  examined  at  once,  as  infection  is  quite  certain  to  be  present. 
Wlien,  two  or  three  days  after  an  operation,  chilly  sensations  and  discomfort, 
followed  by  a  rapidly  rising  temperature  (102°  to  104°  F.),  occur,  with  thirst, 
headache,  pain  in  the  wound,  and  tenderness  and  swelling  of  the  adjacent  soft 
parts,  genuine  surgical  fever,  due  to  the  absorption  of  the  toxic  products  of  fer- 
mentation bacteria,  is  at  hand.  T\'hien  the  temperature  rises  to  a  considerable 
degree  (103°  to  104°  F.),  with  morning  remissions  and  evening  exacerbations 
and  a  well-defined  chill;  and  when,  at  the  same  time,  the  wound  appears  dusky 
and  cedematous  and  is  quite  tender,  suppuration  fever,  due  to  the  absorption  of 
the  toxins  of  poygenic  organisms,  is  present.  The  temperatures  of  saprsemia, 
of  septic  infections,  and  of  pysemia  are  quite  characteristic  in  their  curves.  (See 
the  article  on  this  subject  in  the  present  volume.)  A  high  temperature  with  or 
without  a  chill  in  the  presence  of  an  operation  wound  of  quite  normal  appear- 
ance, suggests  the  onset  of  erysipelas;  and,  if  the  suggestion  prpve  true,  there 
will  soon  be  seen  unmistakable  local  evidences  of  the  disease.  The  existence 
of  a  temperature  suggestive  of  the  presence  of  pus,  with  no  evidence  at  the 
seat  of  the  injury  corroborating  such  suspicion,  often  demands  a  scrutiny  of  the 
most  searching  character  to  reveal  the  seat  of  the  trouble. 

The  Nervous  System. — For  the  purpose  of  this  article  it  will  be  sufficient 
if  we  devote  our  attention  to  sensation,  motion,  reflex  action,  the  modifica- 
;tions  of  special  senses,  and  the  changes  in  nutrition  of  various  parts.  The 
senses  of  touch,  of  pain,  of  heat,  of  locality,  of  pressure,  etc.,  are  of  varied  im- 
portance in  their  relation  to  diagnosis.  The  sense  of  touch  may  be  exaggerated 
(hyperesthesia)  in  neuralgia,  neuritis,  and  disease  of  the  spinal  cord,  and  it 
forms  a  part  of  the  history  of  hysteria  and  spinal  irritation.  It  may  also  be 
exaggerated  by  the  effect  of  local  irritants.  The  sense  of  touch  is  diminished 
(hypffisthesia)  in  disease  and  injury  of  the  posterior  columns  of  the  cord,  of 
the  posterior  part  of  the  internal  capsule,  of  the  parietal  lobe,  and  of  the  pons. 
The  insane,  the  defective,  and  nervous  subjects  may  suffer  in  this  manner.  A 
total  loss  of  the  sense  of  touch  (anajsthesia)  follows  destructive  lesions  of  a 
special  nerve,  of  the  spinal  cord,  or  of  the  brain,  when  the  lesion  destroys  the 
-related  functional  continuity  in  either  of  these  structures.  If  a  nerve  be 
destroyed  the  effect  is  local;  if  the  cord  be  at  fault,  sectional  anesthesia  of  the 
body  is  present  when  the  damage  involves  both  sides,  and  anaesthesia  is  noted 


536  AMERICAN  PRACTICE  OF  SERGERY. 

on  the  opposite  side  of  the  boch-  when  only  one  side  of  the  cord  is  injured. 
In  a  lesion  of  the  brain  ansesthesia  is  commonly  associated  with  hemiplegia 
when  the  latter  is  present.  In  a  circumscribed  lesion  of  the  cortex  only  an 
extremity  may  suffer  ansesthesia.  In  functional  anaesthesia  of  one-half  of  the 
body,  areas  of  irregular  or  of  synmietrical  outline  are  present. 

The  sense  of  pain  (algesia)  differs  in  different  races  and  in  various  persons. 
The  Teutonic  and  Slavonic  peoples  suffer  less,  it  is  thought,  than  do  others.  It 
should  be  appreciated  by  all  concerned  that  persons  of  dull  perce]3tions  and 
phlegmatic  natures  are  less  sensitive  to  pain  than  are  those  of  an  opposite  char- 
acter. Habitual  hardship,  religious  and  other  kinds  of  excitement  blunt  the 
sense  of  pani;  but  refined  restraint  and  associations  and  long  suffering  unfit 
the  sensibilities  to  bear  pain.  The  surgeon  should  be  able  after  a  little  time  to 
differentiate  between  those  who  bear  severe  pain  uncomplainingly  and  those 
who  for  different  reasons  magnify  their  sufferings.  In  any  instance  indiffer- 
ence, heedlessness,  or  superficial  examination  on  the  part  of  the  surgeon  may 
be  followed  by  discomfiture,  criticism,  and  loss  of  professional  station.  The 
kinds  of  pain  are  numerous,  and  to  each  kind  can  often  be  attached  a  special 
degree  of  significance,  particularly  as  indicating  the  seat  of  disease  and  the 
variety  of  tissue  iuA-olved.  Acute  pain  of  a  distressing,  lancinating  character 
is  a  sure  accompaniment  of  an  acute  inflammation  of  a  serous  (especialljO  or 
synovial  membrane.  The  pains  of  neuritis,  and  of  neuralgia,  and  those  caused 
by  a  tumor  and  by  aneurismal  pressure  are  often  severe  and  radiating.  Dull 
pain  occurs  in  acute  inflammation  of  viscera,  in  chronic  inflammations  gener- 
ally, and  in  connective  tissue,  in  which  latter  case  a  throbbing  sensation  is  fre- 
quently present  when  this  tissue  is  acutely  inflamed.  Itching  of  often  torment- 
ing nature  characterizes  acute  inflammation  of  mucous  surfaces,  especially  in 
conjunctivitis,  pharyngitis,  and  urethritis.  Burning  pain  marks  inflammation 
of  the  skin,  as  in  erysipelas,  sunburn,  and  in  other  local  irritating  reactions. 
Boring  or  grinding  pain  is  indicative  of  disease  of  bone  or  of  periosteum,  of  the 
pressure  of  an  aneurism  on  bone,  and  of  gastric  ulcers.  Sickening  pain  char- 
acterizes acute  disease  of,  and  especially  traumatic  pressure  on,  the  testis. 
Throbbing  pain  happens  especially  with  boils,  carbuncles,  plantar  and  palmar 
abscess,  and  in  whitlow,  and  is  dependent  on  the  confinement  of  the  morbid 
process  by  unyielding  overlying  tissues.  Paroxysmal  pain  and  shifting  pain 
are  characteristic  of  such  diseases  as  neuralgia,  colic,  rheumatism,  and  locomo- 
tor ataxia. 

Ordinarily,  the  location  of  the  pain  corresponds  to  the  seat  of  the  morbid 
process  causing  it.  Sometimes  an  injur}-  done  to  the  main  trunk  of  a  nerve,  or 
to  one  of  its  branches,  will  give  rise  to  pain,  not  at  the  seat  of  injury,  but  at  the 
area  supplied  by  such  nerve.  This  is  known  as  transferred  pain.  Such  a  trans- 
ferred pain  occurs  in  cases  in  which  the  trunk  of  a  nerve  or  one  of  its  branches 
is  pressed  upon  by  a  tumor  or  is  subjected   to  some  other  form  of  irritation. 


GENERAL  SURGICAL  DL\GNOSIS.  537 

Then,  again,  in  amputation  for  an  irritable  stump  or  for  disease  or  traumatic 
destruction  of  a  foot  or  leg,  it  often  happens  that  the  distress  continues  after  the 
operation  and  is  assigned  by  the  patient  to  the  amputated  part.  The  pathologic 
change  which  takes  place  in  the  end  of  the  nerve,  in  a  stump,  or  in  a  nerve  which 
has  been  included  in  a  ligature,  produces  a  sensation  like  that  caused  by  the  orig- 
inal infliction.  Pain  at  the  inner  side  of  the  knee  in  disease  of  the  hip,  in  the 
testis  in  renal  disease,  in  the  nipple  in  uterine  disease,  in  the  dorsal  region  in  dis- 
ease of  the  stomach,  in  the  sacral  region  in  disease  of  the  uterus,  in  the  abdominal 
wall  in  Pott's  disease  of  the  spine  and  in  some  cases  of  pneumonia  or  pleurisy, 
especiall}'  in  children — these  are,  all  of  them,  examples  of  transferred  pain, 
sometimes  called  reflex. 

The  determination  of  the  differences  in  the  pain  sense  (algesia)  in  different 
persons,  in  the  different  parts  of  the  body,  and  in  different  diseases,  is  effected 
by  various  devices  and  by  the  hand  of  the  diagnostician.  The  manual  method 
is  a  good  one  when  the  temperature  of  the  parts  and  the  pressure  exer- 
cised are  practically  adjusted.  In  the  use  of  any  measure  for  this  purpose 
care  should  be  exercised  not  to  confuse  the  records  of  the  results.  A  more 
extended  statement  of  these  matters  can  be  found  in  books  devoted  to  special 
diagnosis.  Hypersensitiveness  to  pain  (hyperalgesia)  of  the  keenest  nature 
sometimes  appears  in  inflammation,  and  in  nearly  all  instances  tenderness  is  a 
part  of  the  local  history  of  inflammation  and  of  many  other  disease  processes. 
The  opposite  of  these  conditions  (hypalgesia)  betokens  a  lesion  of  the  nerve,  of 
the  spinal  centres,  or  of  the  focal  area  of  the  brain.  The  integuments  of  idiots 
and  epileptics,  and  also  of  parts  of  the  body  continuously  exposed  to  irritating 
contact,  present  this  manifestation.  A  loss  of  the  sense  of  pain  (analgesia)  is 
a  specially  important  manifestation,  indicating  destruction  of  nerve  tissue  from 
injury,  transverse  spinal  myelitis,  a  tumor,  or  an  injury  of  the  cord,  disease  of 
the  posterior  part  of  the  internal  capsule,  or  disease  or  injury  of  the  parietal  lobe. 
Insanity,  hysteria,  and  hypnotic  suggestion  may  take  a  part  in  the  causative  his- 
tory of  this  change,  and  in  the  last  two  instances  the  exhibit  is  often  of  irregular, 
singular  outline.     Syphilis  may  cause  analgesia. 

The  Heat  Sense  (thermo-sesthesia). —  The  heat  sense  enables  one  to  recognize 
the  differences  in  the  temperature  of  various  things  and  of  different  surfaces. 
The  sense  of  heat  may  be  in  abeyance  in  a  part,  independently  of  that  of  cold, 
or  the  reverse  may  happen ;  also  these  senses  are  sometimes  confused  with  each 
other.  A  complete  loss  of  the  sense  of  heat  (thermo-ansesthesia)  occurs  in  in- 
stances of  destructive  nerve  lesions  similar  to  those  found  in  analgesia,  and  con- 
sequently is  a  symptom  of  great  importance.  In  pressure  myelitis  and  in 
involvement  of  the  gray  matter  of  the  cord  exclusively,  tactile  sense  is  retained, 
but  the  temperature  and  pain  senses  are  lost  (Musser) .  A  loss  of  tactile  sense, 
with  the  loss  of  pain  sense,  happens  in  injury  of  the  trunk  of  a  peripheral  nerve. 

The  sense  of  locality  varies  in  different  parts  of  the  body,  being  most  evident 


538  --LAIERIC-IX  PRACTICE   OF  SL'EGERY. 

on  the  lips  and  least  e^^dent  on  the  body  between  the  scapulse.  This  sensation 
is  lessened  m  the  various  forms  of  hyperesthesia,  especialh'  of  central  origin,  in 
tabes  dorsalis,  and  in  injui'ies  of  the  parietal  lobe.  Tlie  full  significance  of  the 
pressure  sense  has  not  j^et  been  decided,  but  that  it  is  of  importance  in  indicating 
the  structm-al  changes  incident  to  ataxia  and  paralysis  is  evident. 

Impairment  of  the  muscular,  articular,  and  tendinous  senses  occui's  m  cere- 
bral ataxia,  cortical  lesions,  and  those  of  the  crura  and  pons;  also  in  transverse 
injmy  or  disease  of  the  spinal  cord. 

Motion. — The  manner  of  standing  and  that  of  moving  are  fruitful  sources  of 
inquiry  in  the  affected  and  in  the  well.  In  the  latter,  they  are  important  as 
indicating  the  tj^e  of  the  individual:  in  the  former,  the  apparent  de^aation 
from  the  normal  indicates  disease  or  injur}-.  A  normal  person,  standing  with 
the  feet  close  together  and  with  the  eyes  open,  will  .sway  forward  and  back  and 
from  side  to  side  about  an  inch  in  each  du-ection.  The  loss  of  the  muscular, 
articular,  and  tendinous  sensations,  as  in  locomotor  ataxia,  greatly  increases 
the  swajing,  and  the  patient  is  likely  to  fall  if  the  eyes  are  closed.  Disease  of 
the  middle  cerebellar  lobe  and  am-al  vertigo  likewise  cause  this  ataxic  state.  In 
other  respects  the  manner  of  standing  is  suggestive  of  the  infirmity  of  disease  or 
of  old  age.  The  bending  forward,  as  in  paralj-sis  agitans,  in  spinal  disease,  in 
old  age,  and  in  some  instances  of  intoxication:  and  the  bending  backward,  as 
in  pregnancy  or  in  increased  abdominal  weight  from  anj-  cause,  and  also  in 
instances  of  intoxication,  are  manifestations  of  significance,  ^liether  or  not 
the  Imibs  be  alike  or  be  specially  distorted  are  circumstances  which  should  be 
noted. 

As  in  standing,  so  in  walking,  the  body  is  bent  backward  with  increased 
weight  in  front,  and  the  feet  are  more  ■nidely  placed  to  insure  a  fij-mer  support. 
That  limping  and  halting  gaits  distinguish  the  impau'ments  of  rheumatism,  dis- 
ease of  joints,  etc.,  are  facts  which  require  no  special  mention  here.  Tlie  ataxic 
gait  of  locomotor  ataxia,  the  gait  of  alcoholic  intoxication,  of  cerebellar  tinnors 
and  of  cerebellar  ataxia,  the  "prancing"  gait  of  paralyzed  flexors  of  the  foot, 
the  spastic  gait  (rigid  and  stiff-moATng  limbs  and  shuffling  step)  of  lateral  spinal 
sclerosis,  the  involuntary  hastening  gait  of  paralysis  agitans,  the  waddling  gait 
of  lordosis,  of  congenital  dislocation  of  the  hip,  and  of  pseudo-liypertrophic 
muscular  atrophj-,  are  each  not  infrequently  seen. 

Reflex  Action. —  Three  kinds  of  reflexes  will  be  mentioned — the  cutaneous 
or  superficial,  the-  tendinous  or  deep,  and  certain  organic  special  reflexes.  Re- 
flex action  invoh^es  the  passing  of  the  peripheral  stimulus  along  an  afferent  (sen- 
sor}-) ner\-e  to  the  motor  cells  of  a  nerve  centre  in  the  spinal  cord  or  medulla, 
and  the  changing  of  the  stimulus  by  these  motor  cells  into  a  motor  impulse, 
which  is  reflected  along  an  efferent  nen-e  (motor)  to  a  muscle  which  conse- 
quently involuntarily  contracts.  It  therefore  follows  that  these  three  nerA-e 
factors  and  the  muscular  factor  necessars-  in  a  reflex  action  should  each  be 


GENERAL  SURGICAL  DIAGNOSIS.  539 

healthy  if  a  proper  response  is  to  be  obtained,  and  that  when  either  factor  is 
out  of  order  the  reflex  result  is  correspondingly  affected.  The  irritation  of 
the  skin  at  the  selected  site  by  stroking,  picking,  pinching,  etc.,  by  heat  or  cold, 
or  by  chemical  irritants,  and  perhaps  by  a  breath  or  a  breeze,  will  in  the  nor- 
mal state  cause  the  desired  result.  Generally,  conditions  increasing  muscular 
tone  increase  the  reflexes,  and  opposite  conditions  lessen  them.  Reflexes  are 
lessened  when  the  attention  of  the  patient  is  engrossed  in  the  procedure,  and 
increased  if  the  patient  be  required  to  make  a  severe  muscular  effort,  such 
as  the  clenching  together  of  the  fingers  of  each  hand.  In  the  coma  of  uraemia 
and  of  saccharine  diabetes,  attended  with  lessened  muscle  tone,  exaggerated 
reflexes  sometimes  appear,  especially  when  the  muscles  are  much  relaxed 
(Musser). 

The  common  superficial  reflexes  are  the  scapular,  the  epigastric,  the  abdom- 
inal, the  cremasteric,  the  gluteal,  and  the  plantar,  belonging  to  the  spinal  cord; 
and  the  conjunctival,  the  pupillary,  and  the  palatal,  which  are  connected 
with  the  medulla.  The  palatal  reflex  is  lost  in  bulbar  paralysis  and  in  hysteria. 
The  remainder  of  these  reflexes  are  interesting,  and  each  in  turn  signifies  the 
state  of  the  nerve  centre  presiding  over  it. 

The  Deep  Reflexes. — The  deep  reflexes  are  more  particularly  those  of  the 
knee  and  ankle,  to  which  may  be  added  special  ones  of  the  foot.  The  reflexes 
of  the  jaw,  the  elbow,  and  the  wrist,  although  not  as  constant  as  are  the  pre- 
ceding, are  frequently  sought  for,  and  when  present  they  are  given  the  proper 
diagnostic  significance. 

The  knee-jerk,  or  patellar  reflex,  is  invariably  present  in  health.  The 
absence  of  this  reflex,  therefore,  signifies  disease  or  injury  of  one  or  more  of 
the  factors  of  the  reflex  arc.  Hence  the  loss  of  the  jerk  in  neuritis,  in  disease 
of  the  posterior  roots  and  columns  (locomator  ataxia),  in  disease  of  the  anterior 
horns  (poliomyelitis),  and  in  transverse  myelitis  of  the  second  and  third  lumbar 
segments.  The  shock  of  cerebral  hemorrhage,  traumatic  compression  of  the 
brain,  and  traumatism  of  the  spinal  cord  may  cause  abeyance  of  the  jerk;  and 
it  may  be  wanting  in  diphtheria  and  in  other  diseases  of  decided  toxic  nature. 
Exaggeration  of  the  movement  indicates  the  presence  of  a  competent  reflex  arc 
minus  the  inhibiting  influence  of  cerebral  cells  or  of  their  transmitting  fibres 
in  the  lateral  pyramidal  columns.  Increased  irritability  of  the  spinal  cord 
exercises  a  similar  influence.  In  apoplectic  hemiplegia  (shortly  after),  in  cere- 
bellar ataxia,  in  sclerosis  of  a  lateral  column,  in  transverse  myelitis  and  injury, 
in  the  pressure  exerted  by  a  tumor,  and  in  unilateral  lesions  of  the  cord  above 
the  reflex  lumbar  centres  exaggerated  movement  takes  place.  In  a  unilateral 
lesion  the  increase  of  movement  is  on  the  affected  side.  In  tetanus,  strychnia 
poisoning,  and  hysteria,  and  in  spinal  irritation,  this  manifestation  is  present. 

Ankle  clonus  has  the  same  significance  as  the  knee-jerk  phenomenon.  Tap- 
ping of  the  hamstring  tendons  or  the  inner  condyle  of  the  tibia  causes  adductor 


540  a:\ieric-\^'  practice  of  surgery. 

reflexes,  which,  however,  are  not  of  independent  chnical  significance.  Ankle 
clonus  or  tendo-Achillis  reflex  is  present  in  nearly  all  health}^  persons.  Ankle 
clonus  is  present  in  organic  disease  and  may  be  noted  in  functional  trouble, 
and  even  then  organic  change  should  be  suspected  until  disproved.  The 
presence  of  exaggerated  ankle  clonus  or  ankle-jerk  in  a  case  is  sjonptomatically 
equivalent  to  the  presence  of  exaggerated  knee-jerk.  Lesions  of  the  motor 
regions  of  the  brain,  transA'erse  myelitis,  lateral  sclerosis  are  causative  of  ankle 
clonus.  If  the  gi-eat  toe  be  flexed  on  the  sole,  the  foot  on  the  leg,  the  leg  on 
the  thigh,  and  the  thigh  on  the  body,  and  if  at  the  same  time  the  great  toe 
be  tapped  on  the  tendon,  Sinkler's  reflex  -nill  appear.  If,  with  the  lower  limb 
extended,  the  inner  surface  of  the  sole  of  the  foot  be  stroked  with  the  hand 
from  the  heel  upward,  the  toes  ^ill  flex  in  health;  but  if,  instead,  the  great 
toe  be  extended,  either  alone  or  wdth  the  others,  Babinski's  reflex  is  produced, 
indicating  in  both  instances  transverse  injury  of  the  spinal  cord,  as  may  happen 
in  fractiu-e  of  the  spine,  as  well  as  in  transverse  myelitis,  or  in  p}Tamidal  injm-y 
or  disease. 

The  Special  Senses. — The  special  sense  of  touch  has  been  already  con- 
sidered. The  senses  of  sight,  smell,  taste,  and  hearing  will  be  verj-  briefly 
mentioned. 

The  Sense  of  Sight. — Tlie  palpebral  fissm'e  and  the  pupil  are  the  openings 
through  which  light  reaches  the  eye.  The  imopposed  raising  of  the  lid 
in  miconsciousness  and  the  twitching  opposition  attended  with  upturning 
of  the  eyeball  in  hysteria  are  significant  features.  The  swelling  of  the  lids  and 
protrusion  of  the  ej'eball  incident  to  cerebral  thrombosis,  and  the  prompt  pro- 
trusion of  the  ball  and  extraA-asation  of  blood  beneath  the  upper  conjunctival 
fold  in  fracture  through  the  anterior  fossa  of  the  skull,  are  important  mani- 
festations. Contusion  of  the  supraorbital  ridge  or  of  the  contiguous  area, 
attended  with  ruptm-e  of  vessels,  may  cause  an  extravasation  of  blood  to 
develop  gradually  in  the  upper  lid.  Orbital  emphysema  often  is  present  in 
fracture  of  the  nasal  bones,  especially  when  shortly  after  the  accident  the 
patient  makes  an  effort  to  expel  the  nasal  contents.  The  deviation  of  the 
eyeball  from  its  normal  position  should  be  observed,  and  its  relation  to  injury 
at  the  base  of  the  brain,  to  tumor  development,  to  intracranial  disease,  and 
to  functional  change  should  be  carefully  noted,  and  estimated  by  consulting 
special  sources  of  information. 

The  Pupil. — Before  examining  the  pupil,  the  surgeon  should  pay  careful 
heed  to  the  precautionarj-  requirements  commonly  stated  in  books  and  so 
essential  to  the  securing  of  intelligent  findings.  A  changed  outline  of  the  pupil- 
lary margin  suggests  the  activity  of  SA'philis,  of  rheumatism  or  gout,  and  per- 
haps of  tuberculosis. 

Irritative  dilatation  of  the  pupil  arises  from  congestion  of  the  cervical 
portion  of  the  cord  or  from  meningeal  inflammation  or  new  growths  in  this 


GENERAL  SURGICAL  DL4.GN0SIS.  541 

region;  from  high  intracranial  pressure  dependent  upon  surgical  traumatism, 
cerebral  tumors,  or  other  pathologic  changes;  also  from  spinal  and  intestinal 
irritation  and  from  mental  disorders. 

Paralytic  dilatation  of  the  pupil  is  present  in  disease  or  injury  situated 
at  the  base  of  the  brain  and  affecting  the  nucleus  of  the  third  nerve;  in  sinus 
thrombosis  (late);  in  cerebral  softening;  in  fracture  or  dislocation  of  the  cer- 
vical vertebrge,  with  injury  of  the  cord  fcilio-spinal  centre).  Involvement 
of  the  cervical  sympathetic  by  a  tumor  or  an  aneurism  in  the  neck  may  cause 
the  myosis  indicative  of  a  paralyzed  sjanpathetic  or  the  mydriasis  of  an  irri- 
tated one.  Fractures  of  the  cervical  spine  involving  the  cord  will  for  similar 
reasons  produce  a  like  effect  on  the  pupil  of  one  or  both  sides. 

Irritative  contraction  of  the  pupil  happens  in  meningitis,  in  tramnatism, 
in  intracranial  pressure  on  the  third  nerve  or  its  nucleus,  in  hemorrhage,  in 
tumor,  in  abscess,  and  also  in  disorders  due  to  other  causes.  This  form  of 
contraction  follows  excess  Ln  the  use  of  tobacco  and  overstrain  of  the  eyes. 
Traumatism  or  pressure  involving  the  cervical  sympathetic  may  cause  con- 
traction or  dilatation  of  the  pupil,  depending  on  the  severity  of  the  injury. 

Paralytic  myosis  arises  from  involvement  of  the  cervical  sjmipathetic  in 
fractures  or  dislocations  of  the  cervical  spine,  and  also  from  the  pressure  exerted 
by  a  tumor  or  an  aneurism.  Degeneration  of  the  posterior  colunms  of  the 
spinal  cord  and  limrbar  paralysis,  etc.,  cause  it. 

The  influence  of  various  drugs  on  the  changes  in  the  pupil  should  not  be 
overlooked  in  this  connection. 

It  may  be  useful  to  remark  that  the  pupil  may  be  contracted  in  the  rapid 
breathing  of  Cheyne-Stokes  respiration,  and  dilated  Ln  the  interval  of  arrest 
in  the  acts.  A  pupil  irresponsive  to  light  and  darkness,  but  responsive  to 
accommodation  (Argyll-Robertson  pupil),  is  highly  mdicative  of  locomotor 
ataxia.  The  pupil  dilates  in  health  if  the  skin  of  the  neck  is  pinched,  unless 
the  sympathetic  be  destroyed  or  the  patient  have  paresis  or  structural  change 
of  the  eye  itself.  The  alteration  in  the  area  and  outline  of  the  visual  field  is 
exceedingly  important  in  determining  the  presence  of  disease  and  its  local- 
ization in  the  brain,  and  of  disease  of  the  visual  fields  themselves.  The  wide 
scope,  the  great  importance,  and  the  special  technique  of  the  examination  of 
these  cases  render  it  necessary  that  this  work  should  be  done  by  an  expert. 
Injury  or  disease  of  the  base  of  the  brain,  so  located  as  to  involve  either  the 
optic  nerves  or  the  optic  tracts,  the  chiasm,  the  posterior  part  of  the  optic 
thalamus,  the  external  geniculate  body,  the  anterior  quadrate  body,  or  the 
visual  centre  of  the  occipital  lobe,  distvu"bs  or  destroys  sight,  according  to  the 
degree  and  extent  of  the  disease  or  injury. 

The  Sense  of  Smell. — The  sense  of  smell  plays  an  important  part  in  surgical 
diagnosis,  giving  warning  of  impending  disasters  and  of  the  presence  of  unsavory 
things.     It  warns  us  of  approaching  gangrene  of  exposed  and  pulmonary  tissues. 


542  A-MERICAX  PRACTICE   OF  SURGERY. 

determines  the  first  evidence  of  feculent  vomiting,  detects  the  ammoniacal 
odors  of  urinarj'  incontinence,  notes  the  sweet  breath  of  estabhshed  pj^jemia, 
and  otherwise  enables  one  to  detect  hidden  offensive  processes,  and  in  a  general 
way  indicates  cleanliness  of  the  patient,  of  the  fabrics  surrounding  him,  and 
of  the  room  of  his  confinement.  A  modification  or  loss  of  the  sense  of  smell 
may  depend  on  modifying  changes  m  the  mucous  membrane  concerned,  on 
an  injury  of  the  olfactory  bulb  or  tract  or  the  vmcinate  gjTus.  A  modification 
in  degree  or  character,  or  the  loss  of  the  sense  of  smell,  may  follow  a  severe 
blow  on  the  head  or  fracture  of  the  base,  or  attend  hysteria  or  result  from 
structural  changes  in  the  olfactory  centres  of  the  bram. 

The  Sense  of  Taste. — This  sense,  like  that  of  smell,  is  modified  by  the  state 
of  the  mucous  membrane  related  to  the  fmiction;  therefore  the  condition  of 
the  surface  of  the  tongue  and  of  the  soft  palate  is  of  great  importance;  also 
disease  affecting  the  glosso-pharjiigeal,  the  trifacial,  and  facial  ner\-es  is  of 
much  significance  in  this  relation.  The  sense  of  taste  may  be  lost  or  modified 
by  basilar  meningitis,  by  a  tumor  or  an  abscess  at  the  base  of  the  brain,  and 
by  a  fracture  of  the  base  of  the  skull  involving  the  facial  nerve.  Abnormal 
taste  impression  occiu-s  from  taking  bromides  and  other  medicinal  agents. 
Hysteria  modifies  the  sense  of  taste.  The  practically  intimate  association 
between  the  senses  of  taste  and  smell  should  be  considered,  in  order  that  we 
may  avoid  the  error  of  supposing  that  there  is  a  genuine  loss  of  taste,  when 
as  a  matter  of  fact  this  seeming  loss  of  taste  is  due  to  some  cause  which  is 
interfering  with  the  appreciation  of  odors  by  the  sense  of  smell. 

The  Sense  of  Hearing. — To  hear  and  not  to  imderstand  the  meaning  of 
words  is  no  more  embarrassing  and  not  nearly  so  distressing  at  times  as  it  is 
to  be  unable  to  interpret  correctly  the  utterances  of  disease.  Therefore  an 
educated  ear  is  of  superlative  importance  in  promptly  detecting  and  correctly 
interpreting  the  significance  of  morbid  sounds  in  a  patient.  The  surgeon 
should  be  cjuite  as  able  as  the  phj^sician  to  discover  by  auscultation  and  percus- 
sion cA-idences  of  disease  of  the  pleura,  the  lungs,  and  the  heart;  othen\'ise 
he  is  ill  prepared  to  judge  of  their  influence  on  patients  subjected  to  surgical 
interference  or  on  those  suffermg  from  tramnatic  injury,  and  to  estunate  rightly 
the  effect  of  anajsthesia  in  these  circumstances.  This  sense,  the  same  as  the 
preceding  senses,  is  impaired  by  the  state  of  the  external  ear,  i.e.,  by  the  presence 
of  wax,  blood,  pus,  or  of  foreign  bodies  in  the  external  auditory  canal 
and  by  its  occlusion  through  swellmg  of  its  walls.  Lesions  of  the  auditory 
nerves,  of  the  posterior  part  of  the  quadrate,  of  the  internal  geniculate  bodies, 
and  of  the  cortex  of  the  fu'st  and  second  convolutions  of  the  temporal  lobe, 
compromise  or  destroy  the  sense  of  hearing.  Extensive  disease  of  the  middle 
and  internal  divisions  of  the  internal  ear,  fracture  of  the  base  of  the  skull,  con- 
tusion and  laceration  of  the  base  of  the  brain,  tumors,  hemorrhage,  and  inflam- 
mation located  in  this  vicinity   effect    the  same  result.     Syphilis  is  a  fertile 


GENERAL  SURGICAL  DIAGNOSIS.  543 

source  of  deafness.  Tinnitus  of  differing  kinds,  from  established  and  from 
indefinable  causes,  is  frequently  present.  The  variety  synchronous  with  the 
action  of  the  heart  and  arrested  by  compression  of  the  carotid  is  often  depend- 
ent on  vasomotor  paralysis,  aneurism  in  the  temporal  bone  or  at  the  base  of 
the  brain,  etc.,  and  on  inflammation  of  the  middle  ear.  Finally,  the  impor- 
tance of  morbid  auditory  sounds  can  be  properly  estimated  only  by  the  history 
of  the  case  and  by  their  relations  with  morbid  processes  of  the  brain. 

The  Reaction  of  Degeneration. — A  comparison  between  the  normal  respon- 
ses of  nervous  and  muscular  energy  to  galvanic  and  faradic  currents  and 
those  obtained  in  disease,  is  of  great  importance,  indicating,  as  it  often  does, 
the  location  of  disease  in  the  respective  factors  of  the  reflex  arc,  the  nature  of 
the  process,  and  the  probable  outcome  of  the  affliction.  Generally  speaking, 
absence  of  response  to  the  faradic  stimulus,  and  equal  or  greater  response  at 
the  positive  than  at  the  negative  pole,  characterize  tlegenerative  reaction. 
For  the  means  and  the  methods  employed  in  the  securing  of  these  results  and 
in  interpreting  their  importance,  the  reader  is  referred  to  the  special  sources 
of  information. 

Injury  to  the  Spinal  Cord. — Complete  Transverse  Injury. — In  injury  of  the 
spinal  cord,  followed  by  complete  ana-sthesia,  complete  paraplegia,  flaccid 
paralysis,  and  loss  of  tendon  reflex,  with  vasomotor  paralysis  and  absence  of 
voluntary  control  of  the  bladder  and  the  rectmn,  the  inference  is  warranted 
that  complete  transverse  destruction  of  the  cord  has  taken  place.  The  occasional 
presence,  in  these  cases,  of  cutaneous  reflexes  or  of  twitching  of  paralyzed 
muscles  from  pyramidal-tract  irritation,  and  the  absence  of  the  reaction  of 
degeneration,  need  not  cause  a  faltering  in  diagnosis. 

Complete  Unilateral  Injunj. — In  complete  unilateral  injury  of  the  cord, 
complete  paralysis  and  loss  of  muscular  sense  occur  on  the  same  side  as  the 
injury,  and  all  sensation  except  muscular  sensation  is  abolished  on  the  opposite 
side.  The  muscles  energized  by  the  injured  segment  of  the  cord  undergo 
atrophy,  and  below  this  area  spastic  paralysis  and  increase  in  reflexes  occur, 
and  a  zone  of  anaesthesia  is  located  above  the  paralyzed  area. 

Partial  Lesions  of  the  Cord. — The  manifestations  of  partial  lesions  of  the 
spinal  cord  depend  on  the  situation  and  the  extent  of  the  injury.  An  injury 
of  the  pyramidal  tract  may  mterfere  with  the  voluntary  control  of  the  cere- 
brum over  the  ganglion  cells  below  the  seat  of  the  lesion,  and  if  the  inhibition 
continue  spastic  paralysis  will  follow.  Disturbances  invohdng  the  anterior 
horn  interfere  with  the  transmission  of  impulses  from  the  cerebrum  to  the 
periphery,  destroying  the  reflex  arc  and  causing  flaccid  paralysis.  W^ien  in- 
dividual ganglion  cells  or  groups  of  cells  are  destroyed,  the  resulting  secondary 
changes  will  correspond  to  the  nerves  and  muscles  directlj^  associated  with 
them.  In  a  partial  lesion  of  the  pj'ramidal  tract  above  the  cervical  enlarge- 
ment the  lower  limbs  are  more  paralyzed  than  the  upper.     Division  of  the 


544  AMERICAN  PRACTICE  OF  SIT^GERY. 

anterior  roots  Avill  produce  the  same  result  as  the  destruction  of  the  correspond- 
ing ganglion  cells.  A  lesion  of  the  posterior  tract  will  cause  ataxia  and  dis- 
turbances of  muscular,  tendinous,  and  joint  senses  of  the  same  side  as  the  injury, 
and  the  sense  of  touch  may  be  abolished.  In  destruction  of  the  posterior  roots 
sensory  and  reflex  phenomena  are  lost.  A  lesion  of  the  posterior  horn  near  to 
its  base  will  cause  disturbance  of  the  pain  and  temperature  senses.  Destruc- 
tion of  the  roots  of  certain  cervical  nerves  will  affect  the  arms  only,  the  legs 
remaining  normal.  Individual  muscles  and  sensory  areas  are  fortified,  as  a 
rule,  by  a  chief  nervous  supply,  supplemented  by  a  minor  one  at  either  side 
of  this;  therefore,  paralysis  may  not  be  evident  until  after  the  three  associated 
roots  are  destroj^ed.  Injury  involving  the  phrenic  nerve  may  cause  paralysis 
of  the  correspondmg  part  of  the  diaphragm.  Injury  of  the  eighth  cervical 
nerve  or  the  first  dorsal,  or  fracture  of  the  corresponding  vertebra",  or  injury 
to  the  spinal  cord  relating  to  fracture  of  any  of  the  dorsal  vertebra?  from 
the  third  to  the  sixth,  and  even  higher  than  the  sixth,  may  injure  the  cilio- 
spinal  centre  of  the  cervical  sympathetic,  causing  stimulation  of  the  nerve 
with  dilatation  of  the  pupil,  or  paralysis  of  it  with  contraction  of  the 
pupil. 

Vasomotor  Paralysis. — In  severe  injury  of  the  spine,  vasomotor  paralysis 
occurs,  causing  an  increase  of  the  amount  of  blood  in  the  corresponding  parts 
of  the  organism.  The  parts  thus  affected  become  warmer,  the  veins  are  dis- 
tended, and  priapism  is  likely  to  be  present,  especially  in  young  males.  The 
internal  organs  suffer,  perhaps  because  of  resulting  aiitemia;  and  the  organs 
which  suffer  chiefly  are  the  kidneys  and  bladder. 

The  Cerebrum,  Etc. — The  contents  of  the  cranium  are  not  considered  in 
this  article,  except  in  the  general  isolated  manner  already  stated.  The  ex- 
tended scope  and  the  special  importance  belonging  to  this  topic  render  it  mad- 
visable  to  consider  the  subject  in  this  place. 

Effects  of  Traumatic  Lesions  of  the  Spinal  Cord  from  Disease  or  Injury 
(from  Weichmann). — In  this  list  the  effects  of  traumatic  section  of  the  spinal 
cord  through  certain  speciallj^  selected  parts  are  illustrated  onh-  b}'  a  few  of 
the  more  practical  examples: 

Fourth  Sacral. — Paresis  of  the  levator-ani,  sphincter-ani,  and  the  detrusor- 
urinse  muscles. 

Third  Sacral. — Paralysis  of  the  preceding  muscles,  paresis  of  the  rectum 
and  bladder,  loss  of  ejaculatory  power,  and  weakened  erection. 

Second  Sacral. — Loss  of  erection,  plus  the  precedmg  results. 

First  Sacred. — Paralysis  of  anus,  bladder,  and  genitals,  etc. 

Fifth  Lumhar. — Paralysis  of  rectum,  bladder,  and  genitals,  etc. 

Fourth  Lumhar. — Paral3'Sis  of  rectum,  bladder,  and  genitals,  etc. 

Third  Lumhar. — Paralysis  of  rectum,  bladder,  and  genitals,  etc.  Loss  of 
patellar  reflex:  ankle  clonus  may  be  present. 


GENERAL  SURGICAL  DLIGXOSLS.  545 

Second  Linnbar. —FateWar,  tendo-Achillis,  and  cremasteric  reflexes  lost; 
sensation  of  testicle  lost,  etc. 

First  Lumbar. — Patellar  and  cremasteric  reflexes  lost,  tendo-Achillis  reflex 
increased  or  lost,  etc. 

Twelfth  to  Third  Dorsal. — Complete  anaesthesia  dov^Tiward  from  a  little 
below  the  seat  of  injury;  complete  paralysis;  reflexes  of  lower  extremity  lost 
(exaggerated  if  lesion  be  incomplete);  paralysis  of  respiratory  muscles  causes 
diaphragmatic  breathing. 

Second  Dorsal. — Aneesthesia  in  a  line  with  the  second  interspace;  also  at 
inner  surface  of  the  upper  third  of  arm,  plus  the  preceding. 

First  Dorsal. — Pupil  disturbed;  modifications  in  power  and  sensation  of 
upper  extremity  and  of  the  pectoralis  muscles.     Pronator  cjuadratus  weakened. 

Eighth  Cervical. — Upward  increase  of  anesthesia  and  increased  involvement 
of  the  corresponding  muscles;  loss  of  digital  abduction  and  flexion  of  little 
finger  (difficult);  pupil  distended. 

Seventh  Cervical. — Pronation  of  forearm  impaired  or  lost ;  supination  pos- 
sible; hypersesthesia  on  radial  side  of  arm,  forearm,  and  hand:  arm  reflexes 
lost. 

Sixth  Cervical. — Increased  upward  paralysis  and  loss  of  sensation;  diffi- 
culty in  turning  the  head;  reflexes  of  arm  lost.  The  impairment  of  the  respi- 
ratory function  may  soon  cause  death. 

Fifth  Cervical. — Complete  paralysis  of  upper  extremities;  scapula  can  be 
raised;  rotation  and  bending  of  head  difficult;  dyspnoea  from  involvement 
of  phrenic  nerve  causing  paresis  of  the  diaphragm.  Anaesthesia  up  to  the  lower 
part  of  the  neck;   death  not  long  deferred. 

Fourth  to  First  Cervical. — Complete  transverse  lesion  causes  immediate 
death  from  loss  of  power  of  the  diaphragm,  due  to  destruction  of  the  phrenic. 
In  focal  and  imilateral  lesions  of  this  part  of  the  cord  life  will  be  prolonged  and 
recovery  may  take  place. 

The  Genito-urinary  System.— The  attention  of  the  reader  is  directed  to  the 
following  subdiA'ision  of  this  topic : 

1.  The  modifications  of  the  normal  excretory  power  of  the  kidney. 

2.  The  modifications  in  the  manner  of  passing  the  urine. 

3.  The  modifications  in  the  composition  and  character  of  the  urine. 

4.  The  examination  of  the  urethra,  prostate,  bladder,  ureters,  and  kidney. 
Rarely  is  there  anything  of  an  interrogative  nature  in  medicine  or  surgery 

of  more  importance  than  that  of  a  careful  scrutiny  of  the  urine  in  all  surgical 
cases,  especiafly  those  in  which  an  operation  is  required.  Not  one  only,  but 
repeated  examinations  should  be  made  of  the  urme,  of  a  thorough,  searching 
character,  and  by  one  whose  well-known  competency  in  this  respect  admits 
of  no  doubt.  The  finding,  in  a  single  instance,  of  casts  or  albumin  or  of  other 
objectionable  factors   ought  not  to  be  regarded  of  much  greater  significance 


546  AilERICAN   PRACTICE   OF   SURGERY. 

than  that  it  necessitates  a  closer  scrutiny,  when  possible,  before  the  inaugura- 
tion of  operative  action.  However,  when  operative  delay  will  not  bide  longer 
scrutiny,  then  action  based  on  the  full  significance  of  the  findings  should  be 
employed  at  once. 

The  amount  of  the  urine  passed  in  a  given  time,  and  its  chemical  composi- 
tion as  modified  by  the  amount  of  fluid  taken,  are  matters  of  supreme  importance. 
It  is  in  these  circumstances  that  it  is  especially  important  to  investigate  the 
presence  or  not  of  cedema,  high  arterial  tension,  distinct  atheroma,  cardiac 
enlargement,  etc.  And  if  it  happen  that  the  patient  have  nausea,  headache, 
respiratory  distress,  with  contracted  pupils  and  other  well-kno'mi  and  dreaded 
evidences  of  renal  disease,  the  question  of  what  to  do  and  when  to  do  it  is  of 
no  small  moment.  In  these  circumstances  even  a  cautious  administration  of  a 
general  anaesthetic,  an  insignificant  operative  effort,  or  any  act  that  produces 
some  depression  of  the  patient's  strength  may  be  promptly  followed  by  suppres- 
sion of  urine  and  death.  The  easy,  painless  passing  of  a  sound  has  been  known 
to  precipitate  the  final  act.  Heedless  attention  and  incomplete  preparations 
in  operations  in  these  cases  have  cost  many  lives  and  cast  many  shadows  on 
otherwise  justifiable  operative  endeavor. 

The  modifications  in  the  manner  and  frequency  of  passing  urine  are  the  out- 
come of  changes  in  the  channel,  in  the  size  and  shape  of  the  stream,  and  in 
the  urgency  of  the  act.  The  free  flow  and  the  full  oval  stream  of  health  are 
hindared,  thinned,  or  made  dribbling  by  constriction  or  obstruction  of  the 
channel,  by  narrowing  of  the  orifice,  or  by  loss  of  the  expulsive  force.  There- 
fore stricture  of  the  canal  or  the  presence  of  gravel  in  it,  or  narrowing  of  the 
meatus  from  inflammation,  ulceration,  or  some  congenital  defect,  and  loss  of 
the  effect  of  expulsive  power  of  the  bladder  from  paralysis  or  obstruction,  are 
among  the  causes  of  a  deformed  stream. 

Frequent  micturition,  from  intolerance  of  the  bladder  to  the  presence  of  urine, 
or  from  the  presence  in  it  of  a  stone,  a  foreign  body,  or  a  morbid  growth,  is 
quite  common.  Diseases  of  the  spinal  cord  and  tumors  of  the  medulla  so 
modify  the  reflex  centre  of  the  organ  as  to  hasten  the  frequency  of  micturition. 
AH  varieties  of  cystic  inflammation,  prostatic  enlargement,  changes  in  the 
specific  gravity  and  constituency  of  the  urine  dependent  on  diabetes,  oxaluria, 
etc.,  and  cantharidal  medication,  hasten  the  act.  Renal  and  ureteral  calculi 
and  diseases  of  the  rectum,  anus,  and  spinal  cord  add  urgency  to  the  in- 
tent. 

Diminished  frequency  of  micturition  is  less  common  than  the  former  act. 
An  abeyance  or  loss  of  the  normal  sensation  of  the  mucous  membrane  that 
signals  the  presence  of  urine  in  the  bladder,  by  reason  of  the  local  numbing 
effect  due  to  a  fever,  to  cerebral  disease,  to  alcohol,  opium,  etc.,  to  say  nothing 
of  indifference  to  the  desire,  diminishes  the  frequency  of  urination.  Free 
perspiration,  the  ingestion  of  a  small  amount  of  fluid,  spinal  concussion,  delayed 


GENERAL  SURGICAL  DIAGNOSIS.  547 

metabolism,  and  diminished  excretion  from  kidney  disease  accomplish  the  same 
result. 

Retention  of  Urine. — Retention  of  urine  may  be  either  incomplete  or  com- 
plete. Retention  is  dependent  either  on  obstruction  of  the  channel  or  on 
diminished  expelling  force,  or  on  both  combined.  Retention  of  urine  in  severe 
injury  of  the  spine  is  the  result  of  reflex  contraction  of  the  vesical  sphincters, 
dependent  on  the  influence  exercised  by  the  nerve  plexus  in  the  wall  of  the 
bladder,  when  the  spinal  centres  are  at  fault.  Prostatic  disease,  pedunculated 
tumors  of  the  neck  of  the  bladder,  or  foreign  bodies  or  blood-clots  in  that  cav- 
ity cause  retention  by  obstructing  the  inner  orifice  of  the  urinary  channel. 
Inhibition  of  the  lumbar  centre  from  shock,  operations  on  the  urinary  organs, 
rectum,  and  contiguous  parts,  often  cause  retention,  requiring  the  use  of  a  cath- 
eter to  relieve  the  distress.  Overdistention,  voluntary  or  otherwise,  causes 
retention  of  urine;  and  it  should  be  said  at  this  time  that  in  this  condition 
the  bladder  should  not  be  emptied  at  once,  but  partially  emptied  instead, 
thus  avoiding  the  collapse  and  paralysis  of  the  bladder,  with  the  con- 
gestion and  possible  inflammation  of  the  organ  that  often  follow  a  prompt 
emptying. 

A  too  great  emphasis  cannot  be  laid  upon  these  facts.  Complete  retention 
is  infrequent,  as  a  few  drops  escape  from  time  to  time  in  nearly  all  instances. 
Complete  retention  of  urine  may  be  mistaken  for  rupture  of  the  bladder  and 
for  suppression  of  urine.  Partial  retention  is  often  mistaken  for  involuntary 
and  frequent  micturition,  as  it  is  denoted  by  frequent  urinary  acts,  'feeble 
stream,  and  perhaps  by  dribbling  of  urine.  The  introduction  of  a  finger  into 
the  rectum  or  of  a  catheter  into  the  bladder  will  determine  a  difference  between 
complete  I'etention  and  rupture  in  the  former,  and  partial  retention  and  invol- 
untary, frequent  micturition  in  the  latter  instance. 

Overfloiv  of  Urine. — This  expression  signifies  that  there  is  retention  as  well 
as  overflow  of  urine.  The  bladder  becomes  much  distended  and  the  urine 
escapes  periodically,  attended  often  by  painful  vesical  contractions.  Later, 
however,  paralysis  of  the  bladder  ensues  from  the  effect  of  long-continued 
distention  or  overdistention,  and  dribbling  of  urine  is  the  result.  These  cases 
have  been  mistaken  for  frequent  micturition.  A  means  of  differentiating  the 
two  conditions  has  already  been  mentioned. 

Irrepressible  Micturition. — In  this  form  the  bladder,  the  nervous  suppl}-, 
and  possibly  the  urine  itself  are  concerned.  The  diseases  that — in  co-opera- 
tion, perhaps,  with  an  ultra-irritating  urine — increase  the  sensibility  of  the 
mucous  membrane  of  the  bladder  and  its  nervous  supply,  exalt  the  urination 
sensation  to  such  a  degree  as  to  render  proper  control  of  tlie  act  impossible. 
In  acute  cystitis  this  form  of  urination  is  of  common  occurrence. 

Urgent  Micturition. — In  urgent  micturition  the  desire  to  urinate  is  strong, 
yet  controllable.     This  form  is  more  frequent  than  irrepressible  micturition. 


548  a:\iericax  practice  of  surgery. 

Preoccupation,  suggestive  sounds,  as  of  falling  water,  mental  emotions,  as  ap- 
prehension and  fright,  may  each  prompt  the  desire. 

Retarded  micturition  is  characterized  by  the  unusual  length  of  time  occupied 
in  completing  the  act.  The  retardation  may  be  due  to  delay  in  "starting  the 
stream,"  or  to  slowness  in  emptying  the  bladder,  or  to  a  combination  of  both 
of  these  causes.  This  kind  of  m'ination  does  not  call  for  active  interference 
on  the  part  of  the  surgeon.  As  a  matter  of  fact,  the  presence  of  this  condition 
is  appreciated  only  when  the  time  available  for  a  special  completion  of  the 
act  of  urination  fails  to  accomplish  the  purpose.  Delay  in  "starting  the  stream" 
comes  from  slight  obstruction  to  the  passage  of  the  water  or  from  slowness 
of  action  on  the  part  of  the  expulsive  forces.  Atony  of  the  bladder,  special 
nerve  lesions,  mental  emotions,  and  blunted  sensibility,  etc.,  contribute  each 
something  toward  the  production  of  this  condition. 

hiternipted  Micturition. — The  normal  act  of  urination  is  free  and  continuous 
until  near  the  completion,  when  spasmodic  acts  cause  the  escape  of  the  urine 
in  jets,  with  or  without  interruption  of  the  flow.  The  causes  of  the  interrupted 
variety  of  urination  are  to  be  sought  for  in  the  bladder  and  urethra,  and  its 
mechanism  is  largely  of  a  valvular  type,  the  force  of  the  stream  effecting  the 
closure.  Stone,  blood-clots,  pus,  stringy  mucus,  pedimculated  growths,  for- 
eign bodies,  etc.,  are  common  examples  of  the  obstructing  agents.  Congestion 
of  the  prostate  or  of  a  urethral  constriction  often  causes  matutinal  interference 
with  the  stream.  The  causes  of  interrupted  micturition  often  lead  promptly 
to  difficult  micturition. 

Difficult  Micturition. — Difficult  micturition  is  often  associated  with  and 
follows  the  interrupted  kind.  Anything  which  weakens  the  powers  of  expul- 
sion, especially  the  bladder,  or  obstructs  the  flow  of  urine,  is  likely  to  cause 
difficult  micturition.  When  the  difficulty  always  occurs  at  the  beginning 
of  the  act,  urethro-vesical  obstruction  is  indicated;  when  it  occurs  at  the  close 
of  the  act,  stone,  blood-clots,  and  foreign  bodies  in  the  bladder  are  causes  of 
the  difficulty.  The  loss  in  the  contractile  power  in  the  bladder  from  any  cause 
occasions  this  kind  of  trouble. 

Obstructed  Micturition. — Obstructed  micturition  follows  an  advanced  state 
of  the  disorders  which  cause  difficult  micturition.  In  practice  it  is  not  wise 
to  make  a  special  distinction  between  the  obstructed  and  the  difficult  kinds 
of  urination,  since  the  earlier  the  treatment  of  the  cause  the  safer  it  is  for  the 
patients  and  the  better  are  the  results. 

Incontinence  of  Urine. — Incontmence  of  urme  signifies  the  inability  of  the 
bladder  to  restrain  the  escape  of  its  normal  contents,  the  urine  rimning  away 
as  soon  as  it  reaches  the  bladder,  unless  defamed  by  the  force  of  gravity  or 
the  friction  incident  to  the  curves  of  the  urethra.  The  above  statement  defines 
"true"  incontinence.  The  expression  "false"  incontinence  is  misleading  and 
nosologically   inaccurate,   since   it   corresponds   only   to  the   invokmtary  and 


GENERAL  SURGICAL  DLIGNOSIS.  549 

unconscious  acts,  better  and  correctly  expressed  as  ''overflow"  of  urine.  Incon- 
tinence depends  on  any  modification  of  the  bladder  which  permits  early,  con- 
tinuous, and  uninterrupted  flow  of  urine  from  it,  rendering  the  bladder  a  passive 
part  of  the  urinary  canal.  Prostatic  hypertrophy,  interfering  with  the  vesical 
sphincters;  malformation  of  the  bladder;  paralj^sis  of  the  neck  of  the  bladder 
and  of  the  sphincter  muscles  of  the  urethra,  are  causes  of  this  affliction. 

Involuntary  Micturition. — Involimtary  micturition  in  adults  is  an  outcome 
of  both  hypertesthesia  and  anaesthesia  of  the  bladder.  In  children  various 
reasons  are  assigned  for  this  infirmity,  among  which  may  be  mentioned  irri- 
tation of  the  anal  and  urethral  openings  and  insufficiency  of  the  vesical  sphincter, 
allowing  urine  to  enter  the  urethra,  from  which  it  is  promptly  expelled.  In 
adults  hypersesthesia  is  encountered  in  those  who  suffer  great  hardships  and 
deprivation,  and  are  afflicted  with  those  pathological  conditions  which  commonly 
produce  an  irritable  bladder.  In  those  afflicted  with  typhoid  and  t3'phu3 
fevers,  and  in  profound  asthenic  states  from  other  causes,  the  anesthetic  variety 
is  the  one  conmionlj^  observed.  Also  fright  and  shock  often  cause  involuntary 
micturition. 

Painful  Micturition. — Discomfort  and  pain  of  the  urinarj'  tract  occur  before 
micturition,  on  account  of  the  effects  of  causes  that  increase  the  sensibility 
of  the  mucous  membrane  of  the  bladder  and  the  prostate  and  the  irritating 
power  of  the  urine.  Therefore  the  causes  of  these  two  factors  of  the  trouble 
are  indeed  numerous.  Pain  during  micturition  depends  on  diseased  action 
within  the  bladder  or  withm  the  urinary  canal.  Cystitis  and  urethritis  from 
various  causes,  increased  irritating  changes  in  the  urine,  are  the  fertile  sources 
of  this  form  of  infliction.  Pain  after  micturition  may  be  of  two  kinds;  it  may 
either  increase  or  diminish  in  severity  after  the  completion  of  the  act.  The 
diminution  of  pain  after  micturition  indicates  that  contact  of  urine  with  the 
bladder  and  m'ethra,  or  distention  of  the  bladder,  was  the  probable  cause  of 
the  pam.  An  increase  of  the  pain  toivard  the  end  of  micturition  and  after  the 
act  warrants  the  diagnosis  of  stone  in  the  bladder  or  of  enlarged  and  hyper- 
sensitive prostate  from  various  causes.  In  this  variety  of  the  disorder  the 
emptying  of  the  bladder  of  urine  permits  the  organ  to  contract  on  the  stone 
or  foreign  body,  or  on  the  enlarged  and  sensitive  prostate,  causing  severe  pain 
in  the  bladder  and  at  the  end  of  the  penis,  or  possibly  in  the  latter  only.  In 
micturition,  pains  referred  to  the  thigh,  testicle,  or  loin  originate  not  infre- 
quently from  the  pelvis  of  the  kidney  and  from  the  ureter;  those  in  the  sole 
of  the  foot,  calf  of  the  leg,  and  thigh  frequently  depend  on  urethral  stricture. 
Referred  prostatic  pains  appear  in  the  perinseum  and  lower  part  of  the  rectum. 
Hence,  the  local  and  referred  pains  of  micturition  should  be  given  a  careful 
study. 

Force  of  the  Stream. — The  force  of  the  stream  may  be  increased  or  dimin- 
ished.    The  causes  of  urgent  and  of  irrepressible  urination  increase  the  force 


550  AMERICAN   PRACTICE   OF   SURGERY. 

of  the  stream.  The  fcirce  is  diminished  b}'  the  various  causes  of  weakened 
vesical  contraction  and  by  the  presence  of  obstructive  mfluences  in  tlie  urinary- 
canal. 

The  Consideration  of  the  Genito-Urinary  Organs. — This  is  not  the 
proper  place  in  which  to  consider  the  various  diseases  of  the  ui'ethra,  but  we 
may  be  permitted  to  say  a  few  words  with  regard  to  the  relation  of  the  urinary 
canal  to  the  perinteum  and  the  rectum,  as  bearing  on  the  important  subject 
of  urinar}'  extravasation.  The  perinseum  should  be  examined,  both  deeply 
and  superficially,  in  order  properly  to  interpret  the  changes  that  arLse  from 
urinary  extravasation  at  this  situation.  The  deep  early  induration  incident 
to  rupture  of  the  membranous  portion  of  the  urethra — an  induration  which 
is  felt  in  front  of  and  from  within  the  anus — contrasts  strongly  with  the  more 
extended  and  superficial  induration  which  follows  an  escape  of  urine  either 
from  a  deep-seated  rupture  or  from  a  rupture  of  the  anterior  portion  of  the 
urethra.  It  is  a  matter  of  great  practical  importance  that  the  surgeon  should 
be  thoroughly  familiar  with  the  anatomical  relations  of  the  different  structures 
in  this  region:  the  bulb  of  the  urethra,  the  median  line  of  the  perinieum,  the 
rami  of  the  pubes  and  ischium,  and  the  tuberosities  of  the  latter. 

The  Prostate. — The  condition  of  the  prostate  in  health  and  in  disease  can 
be  estimated  by  the  finger  introduced  into  the  rectum.  The  size,  shape,  and 
sensibility  of  the  organ  may  thus  easily  be  ascertained.  The  sensibility  of 
the  structure  and  the  deviations  of  the  prostatic  sinus  can  also  be  learned  by 
means  of  suitable  instruments  introduced  into  the  urethra.  Consequently 
it  is  an  easy  matter  to  determine  the  presence  of  prostatic  enlargement  and 
to  ascertain  with  reasonable  certainty  the  nature  of  obstructive  changes  in 
the  prostatic  urethra.  The  relations  between  pain  and  urination  in  various 
kinds  of  prostatic  interference  with  the  act  have  been  given  already  as  full 
consideration  as  our  space  will  permit.  It  is  necessary  to  remember,  however, 
that  a  sensitive  prostate  and  the  presence  of  a  stone  in  a  sensitive  bladder 
cause  similar  pains  after  urination,  and  for  similar  reasons;  also  that  a  mov- 
able stone  in  the  bladder  arrests  the  urinary  flow  promptly,  and  that  a  change 
in  the  position  of  the.  patient  may  as  promptly  relieve  the  pain;  and,  finally, 
that  an  enlarged  prostate  slowly  diminishes  the  flow,  which  is  not  influenced 
by  change  in  position.  With  the  fimger  in  the  rectum  the  seminal  vesicles 
can  be  felt  high  up,  on  either  side  of  the  prostate.  At  the  same  time  the  soft 
area  of  a  prostatic  abscess,  the  hard  area  of  a  prostatic  calculus,  the  hard  and 
irregular  nodular  outlines  of  malignant  and  tuberculous  disease,  may  also  be 
determined. 

The  Bladder. — The  relative  situation  of  the  bladder  in  the  pelvis  of  the 
different  sexes,  different  ages,  and  at  different  periods  following  micturition 
is  exceedingly  important  in  cystotomy  and  puncture  of  the  bladder  above  the 
pubis;   also  in  the  instances  of  external  violence  directed  from  above  into  the 


GENERAL  SURGICAL  DIAGNOSIS.  551 

pelvis  (wagon  wheel,  kick,  etc.)  or  in  fracture  of  the  pelvis.  In  these  circum- 
stances the  greater  the  amount  of  urine  in  the  bladder  the  greater  is  the  danger 
of  rupture,  and  conversely.  The  outline  of  an  overdistended  bladder  and  the 
outline  of  an  enlarged  uterus  are  each  of  prime  importance,  and  often  of  embar- 
rassing and  disastrous  significance  when  mistaken  for  each  other.  The  history 
of  a  long  interval  in  urination,  attended  by  the  development  of  an  oval,  supra- 
pubic, abdominal  tumor,  disappearing  coincidently  with  violence  of  any  kind 
or  without  apparent  cause,  should  arouse  serious  apprehension  and  corre- 
sponding activity  regarding  rupture  of  the  bladder.  If,  however,  the  bladder 
has  become  contracted,  because  of  disease  or  obstruction  of  the  urinary  channel, 
less  distention  and  correspondingly  less  danger  will  attend  the  case  in  these 
circumstances. 

The  bladder  can  be  examined  by  means  of  the  finger  introduced  into  the 
rectum;  and  it  can  be  examined  from  the  inside  by  the  aid  of  various  devices 
constructed  for  that  purpose  (consult  the  article  on  Surgery  of  the  Bladder,  in 
a  later  volume).  A  certain  amount  of  information  can  also  be  obtained  by 
percussion,  by  palpation  through  the  overlying  abdominal  wall,  and  by  com- 
bined palpation  and  the  use  of  the  x-ray.  By  means  of  the  finger  introduced 
into  the  rectum  one  can  determine  the  presence  of  a  collapsed  or  distended 
bladder  (useful  in  detecting  rupture  of  the  bladder),  of  a  sensitive  or  insensi- 
tive organ,  of  the  presence  in  it  of  a  foreign  body,  the  extremity  of  an  instru- 
ment, or  a  solid  growth;  and  especially  are  these  features  emphasized  by  com- 
bined manipulation.  A  knowledge  of  the  points  of  reflection  of  the  peritoneum 
from  the  bladder  should  be  known,  so  that  a  proper  estimate  may  be  made 
of  the  question  whether  or  not  extraperitoneal  or  intraperitoneal  rupture  of  the 
organ  has  taken  place.  Combined  manipulation,  with  the  hand  on  the  abdo- 
men and  an  instrument  in  the  bladder,  may  be  practised,  but  always  with 
exceeding  caution.  As  I  am  convinced,  from  personal  knowledge,  that  errors 
with  regard  to  this  matter  are  of  frequent  occurrence,  I  will  again  caution 
against  the  mistaking  of  the  involuntary  act  and  the  overflow  that  attends  an 
overdistended  bladder,  for  unobstructed,  frequent  micturition.  The  x-ray  may 
reveal  the  presence  of  a  stone  or  a  foreign  body  in  the  bladder,  or  the  existence 
of  a  fracture  or  a  dislocation  of  the  pelvis. 

The  Ureters. — The  condition  of  the  ureters  can  be  ascertained  by  nieans  of 
external  manipulation,  by  cystoscopy,  by  direct  catheterization  of  these  chan- 
nels, and  by  explorative  incision. 

In  thin  subjects  and  in  those  with  much  thickening  or  distention  of  the 
ureter  from  inflammation,  from  an  accumulation  of  urine,  from  the  presence 
of  a  stone,  or  from  any  other  cause,  external  palpation  may  serve  to  locate 
the  tube,  especially  the  lower  part,  provided  vaginal  or  rectal  palpation  be 
added  to  the  abdominal  effort.  In  stout  subjects,  on  the  other  hand,  external 
palpation  can  offer  no  encouragement;  at  the  most,  it  may  enable  one  to  ascer- 


552  AMERICAN  PRACTICE   OF  SURGERY. 

tain  the  presence  of  a  tumoi'  or  of  tenderness  at  or  near  the  site  of  the  ureter. 
However,  by  the  aid  of  cystoscopy,  supplemented  with  catheterization  of 
the  ureters,  it  is  possible  to  determine  whether  or  not  the  canal  be  permeable 
or  be  obstructed  Avith  stone  or  inflammatory  products,  and  whether  it  be  dis- 
charging healthy  or  abnormal  urine.  The  latter  fact  can  be  made  out  by  the 
cystoscope  alone,  and  thus  the  state  of  each  of  the  kidneys  may  be  decided. 
Segregation  of  urines  may  be  practised  for  a  similar  purpose.  Increased  fre- 
quency of  urination  attends  pain  in  the  ureter,  especially  when  it  is  due  to  a 
passing  calculus.     The  kidney  also  may  suffer  from  referred  pain  in  these  cases. 

The  Kidney. — A  kidney  is  said  to  be  movable  when  the  entire  lengtii  can 
be  examined,  and  to  be  -floating  when  it  can  be  freely  moved  in  any  direction. 
Misplacement  of  the  kidney  happens  about  once  in  one  thousand  cases.  The 
misplacements  may  be  slight  or  excessive,  or  of  little  degree,  and  the  misplaced 
organ  may  occupy  the  iliac  fossa  or  may  lie  against  the  promontory  of  the 
sacrum  or  between  the  rectum  and  bladder,  etc.  Sometimes  both  kidneys 
are  misplaced.  A  single  kidney  happens  once  in  twenty-fovu-  hundred  autop- 
sies (Morris).'  In  the  absence  of  a  kidney  the  opposite  one  is  much  increased 
in  size.  In  a  physiologically  enlarged  kidney  the  normal  outlines  of  the  organ 
are  maintained.  In  enlargement  from  morbid  causes,  as  from  distention  or 
from  a  tumor,  the  outline  will  be  changed,  but  the  modification  will  vary  accord- 
ing to  the  location,  the  extent,  and  the  nature  of  the  disease.  Overdistention 
and  acute  malignant  changes  obliterate  the  normal  outlines  of  the  organ,  often 
fusing  them  with  those  of  the  contiguous  soft  structures.  As  a  rule,  the  inner 
outline  maintains  the  longest  a  distinguishing  feature — the  notch  indicating 
the  hilum.  The  right  kidney  may  be  mistaken  for  a  distended  gall  bladder, 
the  left  for  the  spleen.  The  presence  of  the  colon  in  front  and  on  either  side 
of  the  kidney,  with  tympanitic  resonance  when  the  intestine  is  distended; 
the  greater  freedom  of  movement  of  the  gall  bladder  on  manipulation  or  when 
the  position  of  the  patient's  body  is  changed,  unless  the  gall  bladder  be  adherent 
— in  which  case,  however,  it  still  will  be  more  movable  than  the  kidney;  the 
superficial  location  of  the  gall  bladder  as  contrasted  with  the  deep  position 
of  the  kidney,  with  often  a  marked  interval  between  them,  discoverable  when 
pressure  is  made  upon  the  gall  bladder — these  are  the  important  diagnostic 
features  which  should  be  borne  in  mind  when  an  examination  of  the  kidney 
of  the  right  side  is  made.  On  the  left  side  the  shape  and  the  location  of  the 
spleen,  its  movements  on  respiration,  the  sharpness  of  its  border,  and  the  fact 
that  it  is  in  front  of  and  the  kidney  behind  the  colon,  are  the  diagnostic  features 
of  importance.  So  far  as  the  kidney  is  concerned,  the  following  favorable 
facts  should  be  remembered  by  the  surgeon :  the  relation  of  the  organ  to  the 
peritoneum;  its  accessibility  from  the  loin  for  operative  purposes;  and  its 
possession  of  a  fatty  capsule. 

Finally,  there  remain  to  be  mentioned  the  following  common  manifesta- 


GENERAL  SURGICAL  DIAGNOSIS.  553 

tions  of  morbid  action  on  the  part  of  the  geni to-urinary  organs :  the  connection 
of  priapism  with  injury  of  the  spinal  cord,  the  retraction  of  the  testis  in  renal 
colic,  the  elongation  of  the  prepuce  in  stone  of  the  bladder,  urinary  inconti- 
nence, and  local  itching. 

The  Employment  of  a  General  Anesthetic  for  Diagnostic  Purposes. 

The  surgeon  ma}-  often  be  very  greatly  aided  in  his  efforts  to  make  a  diag- 
nosis by  administering  to  the  patient  a  general  anesthetic.  This  procedure 
not  only  renders  the  manipulations  painless,  but  also  causes  complete  relaxa- 
tion of  all  the  muscles,  and  thus  renders  it  possible  for  the  surgeon,  in  an  obscure 
case — e.g.,  an  abdominal  tumor  or  an  injured  hip  or  elbow — to  determine 
the  outlines  and  nature  of  the  tumor,  and  to  ascertain  the  character  and  full 
extent  of  the  injury.  The  fright  of  children  and  the  serious  apprehension  of 
adults  in  regard  to  pain,  as  well  as  their  sensitiveness  about  ha^dng  their  private 
parts  exposed,  may  be  thus  entirely  relieved.  It  should  be  remembered,  how- 
ever, that  relief  from  pain  by  this  means  does  not  give  the  surgeon  licence  to 
exercise  unnecessary  or  unduly  prolonged  or  needlessly  severe  efforts  in  attaining 
the  purpose.  On  the  contrary,  great  discretion  should  be  exercised  in  these 
circumstances,  and  often  actual  restraint  is  needed  on  the  part  of  the  surgeon 
to  prevent  the  adding  of  increased  hurt  to  previous  injury,  more  especially 
in  the  case  of  contentious  persons.  Only  sufRcient  force,  and  that  under  intel- 
ligent guidance,  should  be  used  to  achieve  the  aim  in  view.  The  giving  of  an 
anaesthetic  only  for  the  purpose  of  eliciting  crepitus  in  a  fracture  that  should 
be  determined  by  other  means,  is  a  use  of  opportunity  that  can  be  seldom 
justified.  The  rupture  of  an  abscess  by  the  employment  of  a  degree  of  force 
which  it  is  difficult  to  estimate  under  these  circumstances  is  a  result  deeply 
to  be  regretted. 

Local  ancesihesia  of  rectal  and  other  passages  is  sometimes  employed  to 
lessen  the  infliction  of  pain  during  an  examination.  The  employment  of  atropia 
in  the  eye,  of  tuberculin  for  tuberculous  invasion,  of  specific  treatment  as  a 
test  of  syphilis,  of  pilocarpine  to  test  the  response  of  the  cervical  sympathetic, 
of  cathartics  to  evacuate  the  bowels,  are  illustrations  of  the  use  of  drugs  in 
diagnosis.  The  fact-  that  opium  masks  symptoms,  and  may  for  this  reason 
mislead  the  surgeon,  should  be  kept  in  mind. 

Operative  procedures  of  a  simple  or  severe  nature  are  emploj^ed  for  diagnos- 
tic intent,  and  always  the  strictest  aseptic  technique  should  mark  the  per- 
formance. The  use  of  the  trocar  and  cannula,  the  aspirator,  the  aspiratory 
needle,  and  the  hypodermic  syringe  to  determine  the  presence,  the  situation, 
and  the  nature  of  a  morbid  process  related  to  various  parts  of  the  body,  is 
already  Avell  understood.  The  danger  of  infection  from  the  escape  of  fluid, 
especially  in  to  the  peritoneal  cavity  in  the  absence  of  adhesions;  the  danger  of 


554  AMERICAN  PRACTICE  OF  SURGERY. 

infecting  the  healthy  skin  from  puncturing  an  underlying  malignant  growth, 
and  of  the  involvement  of  important  overlying  tissues  in  instances  of  opera- 
tive approach,  are  illustrations  of  danger  demanding  thoughtful  care.  The 
puncturing  of  the  thorax,  the  abdomen,  and  the  bladder  are  usually  innocent 
procedures,  but  of  sufficient  import  to  exact  exceeding  care  in  their  use.  The 
incision  of  a  tumor  for  diagnostic  purposes,  followed  by  its  removal  at  once 
if  the  conditions  found  demand  it,  or  by  closure  of  the  wound  if  further  operative 
interference  be  found  unnecessary,  is  sometimes  practised  in  tumor  of  the 
breast  and  elsewhere.  Malignant  infection  of  the  healthy  parts  is  regarded 
as  possible  in  this  measure.  Abdominal  explorations  should  not  be  done  solely 
for  the  purpose  of  making  a  diagnosis,  but  with  the  further  idea  of  gaining 
additional  knowledge  regarding  the  prognosis  and  treatment  of  a  case.  There- 
fore, before  making  an  explorative  incision,  one  should  stop  to  consider  the 
advantages  to  the  patient  that  may  follow  the  act.  The  pi'actice  of  making 
an  explorative  incision  to  determine  only  a  question  in  prognosis  is  unjusti- 
fiable, except  when  requested  by  a  patient  having  a  full  appreciation  of  the 
important  facts  in  the  case.  The  cutting  into  an  inoperable  malignant  tumor 
can  rarely  be  justified,  as  no  physical  gain  can  follow  and  decided  loss  is  almost 
sure  to  result.  The  idea  that  an  explorative  incision  is  devoid  of  danger  has 
cost  many  lives,  saddened  many  hearts  and  homes,  and  impaired  many  pro- 
fessional reputations. 


Editors'  Note. — The  article  on  Blood  Pressure,  etc.,  referred  to  on  p.  533, 
was  to  have  been  published  in  the  present  volume,  immediatel}^  after  that  on 
Surgical  Shock,  but  the  sudden  illness  of  the  author  has  compelled  us  to  trans- 
fer it  to  the  Appendix,  at  the  end  of  vol.  viii. 


THE  BODY  FLUIDS  IN  GENERAL  SURGICAL  DISEASE, 

WITH  SPECIAL  REFERENCE  TO  THEIR  DIAGNOSTIC  VALUE. 
By  HARLOW  BROOKS,  M.D.,  New  York  City. 


Although  the  study  of  the  body  fluids  has  been  largely  developed  in  connec- 
tion with  surgical  science,  the  discussion  of  this  subject  is  now  more  extensively 
treated  in  works  relating  to  internal  medicine.  This  is  not  as  it  should  be,  for 
the  well-equipped  surgeon  must  have  at  his  command  all  the  facts  and  methods  of 
medical  study,  since  in  so  many  instances  surgery,  both  in  diagnosis  and  in  treat- 
ment, is  now  called  upon  to  assist  or  supersede  the  methods  of  internal  medicine. 

Since  the  space  at  our  command  is  so  limited,  it  has  seemed  best  to  me  to 
consider  the  subject  entirely  from  the  practical  rather  than  the  theoretical  stand- 
point, and  for  this  reason  I  shall  devote  myself  chiefly  to  matters  of  diagnostic 
importance,  for  it  is  in  this  direction  that  study  of  the  body  fluids  has  proven  of 
greatest  utility  to  us. 

References  to  technique  and  methods  of  examination  have  been  omitted,  for 
the  reason  that  space  does  not  permit  of  their  full  statement,  and  incomplete 
discussions  of  technical  matters  are  more  misleading  than  they  can  possibly  be 
useful.  Full  elaboration  of  this  subject  is  furnished  in  such  special  arid  general 
text-books  as  those  of  Ewing,  Wood,  Simon,  and  Mallory  and  Wright.  But  very 
little  reference  will  be  made  to  the  characteristics  of  the  normal  fluids  of  the 
body,  as  it  is  assumed  that  the  reader  is  already  familiar  with  them. 

Although  the  data  secured  from  the  study  of  the  body  fluids  often  appear  to 
be  of  the  most  conclusive  nature  possible,  in  diagnosis  particularly  they  should 
never  be  considered  absolutely  final,  but  must  be  accorded  the  value  of  symp- 
toms only. 

There  is  now  perhaps  a  tendency  in  modern  medicine  to  overvalue,  as  in  the 
past  the  inclination  has  been  to  undervalue,  the  evidence  of  the  test  tube  and 
the  microscope;  but  the  broad-minded  clinician  must  first  secure  all  the  evidence 
at  hand,  and  then  with  careful  judgment  eliminate  the  unimportant,  until  final 
diagnosis  rests  not  on  any  one  sign  or  symptom,  but  on  all. 

THE   BLOOD. 
The  examination  of  no  one  tissue  yields  more  valuable  data  in  general  sur- 
gical diagnosis  and  prognosis  than  does  that  of  the  blood.    This  examination 
may  be  special,  brief,  and  very  limited  in  its  extent;  or  in  other  cases,  where  a 
broad  and  comprehensive  view  of  not  only  the  special  condition  but  also  of  the 

555 


556  .^ilERICAN  PRACTICE  OF  SLTIGERY. 

general  nutritive  functions  of  tlie  bodj'  is  desirable,  a  detailed  study  may  be 
necessary,  and  will  richly  repay  the  time  spent  on  it. 

A  great  deal  of  important  evidence  can  be  elicited  even  by  the  most  simple 
and  primitive  examination.  Thus,  the  puncture  of  the  finger-tip  or  lobe  of  the 
ear,  with  close  observation  of  the  exuding  drop,  judged  from  the  rapidity  of  the 
flow,  may  give  the  required  data  as  to  the  relative  abundance  of  blood  fluids.  In 
other  instances,  where  it  is  desirable  to  ascertain  perhaps  the  coagulability  of 
the  blood  as  a  preliminarj-  to  operation,  tolerably  definite  information  may  be 
thus  obtained  by  timing  the  clotting  of  the  drop  as  it  flows  from  the  minute 
wound,  though  this  can  be  determined  with  absolute  accuracy  and  almost  as 
easily  by  the  use  of  the  extremely  simple  and  ingenious  coagulometer  of  Biffi. 
In  cases  suspected  of  hsemophilic  tendencies,  this  same  simple  observation  dis- 
closes a  condition  the  knowledge  of  which  may  save  the  operator  serious  diffi- 
culties. In  this  disease  it  is  well  for  us  to  recall  that,  in  at  least  some  cases,  the 
blood,  when  removed  from  the  body,  clots  in  very  nearly  the  normal  time,  as  in 
a  case  recently  reported  by  me ;  the  primary  essential  lesion  in  haemophilia  being 
not  in  the  blood,  but  in  the  blood-vessels.  Clot  formation  is  notably  delayed  in 
many,  but  not  all,  cases  of  jaundice,  particularly  when  the  haemoglobin  percent- 
age is  low;  and  this  should  be  taken  into  consideration  when  operation  on  javm- 
diced  and  anaemic  patients  is  contemplated.  Recent  hemorrhage  is  suggested 
by  increased  fibrin  formation,  and,  when  this  factor  has  been  watched  through- 
out the  course  of  the  disease  and  a  rapid  increase  is  discovered,  it  is  strongly 
indicative  of  hemorrhage,  perhaps  from  obscure  and  unsuspected  foci.  Even 
the  presence  or  absence  of  anaemia  of  marked  degree  may  be  roughly  suspected 
by  this  method,  although  in  all  cases  of  this  nature  a  thorough  examination  of 
the  blood  should  be  made. 

The  percentage  of  haemoglobin  is  often  a  measure  of  the  gravity  or  of  the 
duration  of  the  disease  process,  and  it  is  therefore  specially  important  to  ascer- 
tain this  when  the  question  of  operation  arises ;  for  it  is  much  better  in  many 
cases,  in  which  immediate  operative  relief  is  not  demanded,  to  wait  until  a 
higher  percentage  can  be  secured,  not  onh^  because  both  chloroform  and  ether 
greatly  depress  the  haemoglobin  content,  but  also  because  in  cases  of  this 
nature  convalescence  is  prolonged  and  even  the  chances  of  ultimate  recovery 
may  be  jeopardized.  This  seems  particularly  true  in  cases  of  chlorotic  anaemia, 
in  which,  as  a  rule,  preparatory  treatment  of  the  anaemia,  for  even  the  brief 
period  of  a  few  days,  greatly  improves  the  general  condition  of  the  patient. 

A  knowledge  of  the  haemoglobin  percentage  is  often  of  assistance  in  the  dif- 
ferential diagnosis  of  malignant  and  innocent  neoplasms,  for,  as  a  rule,  it  will  be 
found  that  the  percentage  either  diminishes  rapidly  or  remains  stationary  at  a 
low  figure  in  the  malignant  tumors,  while  severe  or  progressive  anaemia  is  rare 
in  innocent  growths,  except  when  it  is  due  to  loss  of  blood  or  to  some  other  more 
or  less  independent  pathological  condition. 


EXPLANATION   OF  PLATE   II. 

(Preparations  Stained  by  Goldliorn's  "One  Solution.") 

Fig.  1. — Myelogenous  Leukaemia.  The  patient  was  a  man  42  years  of  age.  He  presented  himself 
on  account  of  an  abdominal  tumor,  which  was  found  to  be  a  greatly  enlarged  spleen.  Lymph  nodes  but 
slightly  enlarged.  The  case  presented  but  slight  anaemia,  and  its  real  nature  was  not  suspected  until 
the  blood  was  examined. 

The  cut  shows  the  presence  of  frequent  very  large  mononuclear  white  corpuscles  (myelocytes),  the 
cytoplasm  of  which  is  studded  with  neutrophilic  granules.  The  presence  of  these  myelocytes  typifies 
leukaemia  of  tliis  special  variety. 

Fig.  2. — Severe  Secondary  Anaemia,  Clinically  Simulating  Pernicious  Anaemia,  but  Found  to  be 
Due  to  Chronic  Atrophic  Gastritis.     Htemoglobin,  53%;    red  corpuscles,  2,004,000;    leucocytes,  6,150. 

The  illustration  shows  marked  variation  in  size  and  deformation  (poikilocytosis)  of  the  red  cor- 
puscles. The  amount  of  haemoglobin  contained  in  the  cells  is  very  irregular;  some  of  the  cells  are 
deficient  in  haemoglobin,  while  others  contain  more  than  the  normal  quantity.  Polychromatophilic  or 
granular  degeneration  is  shown  in  two  large  red  cells  (macrocytes).  Complete  recovery,  in  so  far  as  the 
blood  condition  was  concerned,  followed  appropriate  treatment. 

Fig.  3. — Ljinphatic  Leuka?mia.  Male,  aged  47  years.  Enormous  enlargement  of  superficial  and 
deep  lymph  nodes,  hver,  and  spleen.  Slowly  progressive  enlargement  of  lynii:)h  nodes  extending  over 
the  past  seven  years,  first  noted  in  superficial  cervical  nodes. 

The  figure  shows  a  tj^^ical  microscopic  field  illustrating  the  marked  relative  and  absolute  increase 
in  the  lymphocytes.  The  preponderance  of  these  cells  characterizes  this  leukaemia  and  distinguishes  it 
from  the  myeloid  form  shown  in  Fig.  1.  Two  myelocytes  are  present  in  the  field.  The  ease  presented 
profound  aniEmia  (Haemoglobin  42%),  as  indicated  by  the  very  pale  red  corpuscles,  a  few  of  which, 
however,  show  an  abnormally  liigh  hajmoglobin  index. 

Fig.  4. — Severe  Secondary  Anaemia,  Following  Long-continued  Haemorrhage  (Epistaxis  and 
Menorrhagia).  Hemoglobin,  30%;  red  cells,  3,112,000;  leucocytes,  9,500.  Note  the  deformity 
(poikilocytosis)  and  the  low  h:Emoglobin  index  of  the  red  corpuscles.  Some  of  the  corpuscles  show 
beginning  endoglobular  degeneration. 

Fig.  5. — Anemia  Five  Days  After  Severe  Hemorrhage.  Traumatic  rupture  of  the  spleen  with 
splenectomy.     Complete  recovery. 

The  blood  shows  variation  in  haemoglobin  index,  a  few  macrocytes,  slight  endoglobular  degenera- 
tion and  occasional  polychromatophilic  degeneration  of  the  red  corpuscles.  A  slight  polynuclear 
leucocytosis  was  present  in  this  case. 

Fig.  6. — Fatal  Ana;mia  Terminating  Mixed  Intestinal  Infection  with  the  Hook  Worm  (Uncinaria 
americana),  and  a  Tape  Worm  (Ta?nia  saginata).  The  case  was  originally  diagnosed  as  one  of  duodenal 
ulcer. 

The  figure  shows  the  marked  degeneration  and  deformation  of  the  red  corpuscles;  endoglobular 
changes  are  very  marked  in  the  average  red  cell.  One  nucleated  red  corpuscle  (normoblast)  is  present. 
The  eosinophilia,  usually  marked  in  cases  of  this  kind,  was  but  slightly  developed  in  this  instance  (3% 
to  5%),  probably  on  account  of  the  lack  of  reaction  on  the  part  of  the  greath'  depressed  body  tissues. 


AMERICAN  PRACTICE  OF  SURGERi". 


PLATE   n. 


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Plate    Illustrating  Various   Blood  Lesions 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  557 

Whenever  ansemia  occurs  in  any  surgical  disease,  its  nature,  whether  primary 
or  secondary,  and  its  cause  should  always  be  sought  for.  In  most  instances  this 
necessitates  a  count  of  the  red  blood  corpuscles,  which  adds  more  than  enough 
valuable  data  to  repay  the  small  expenditure  of  lime  necessary  for  carrying 
out  this  reasonably  simple  procedure.  It  is  in  this  way,  and  also  by  the  deter- 
mination of  the  hfemoglobin  percentage,  that  the  differentiation  between  pri- 
mary (Plate  IV.,  Fig.  2)  and  secondary  anjemia  is  made.  Furthermore,  in  those 
cases  in  which  disease  of  the  internal  viscera  is  suspected,  it  often  directs  the 
queries  of  the  surgeon  in  the  right  direction.  Even  more  important  than  the 
count  of  the  red  cells  is,  in  many  cases,  the  examination  of  these  bodies  when 
properly  prepared  and  stained  by  one  of  the  modern  polychrome  methylene -blue 
methods.    For  example,  cachectic  antemia  (Plate  II.,  Fig.  2,  and  Plate  III.,  Fig. 


Fig.  142. — Ova  and  Embryos  of  Filaria  immitis ;  from  the  Blood  of  an  Infected  Sea  Lion. 

1),  in  which  one  sees  marked  poikilocytosis,  polychromatophilic  and  other  de- 
generative alterations  in  the  red  corpuscles,  may  be  distinguished  from  the  an- 
aemia of  a  person  who  is  convalescmg  from  an  acute  hemorrhage  by  the  charac- 
teristic picture  of  pale  red  cells  and  numerous  normoblasts  which  the  latter 
condition  presents  (Plate  II.,  Fig.  5).  Malignant  growths  may  also  be  thus  in  part 
differentiated  from  those  of  an  innocent  nature.  In  my  opinion,  careful  study 
of  the  red  blood  cells,  of  their  size  and  shape,  of  the  presence  or  absence  of  nu- 
clei, and  of  the  changes  in  their  cytoplasm,  is,  in  the  majority  of  cases,  more 
instructive  than  the  simple  red-cell  count  with  which  so  many  clinicians  are  con- 
tent. Malarial,  trypanosomatous,  or  relapsing-fever  infections  discovered  in  this 
direct  and  absolute  way  may  fully  account  for  an  otherwise  confusing  pyrexia 
or  a  splenic  tumor  (Plate  III.,  Figs.  2  and  3);  in  the  same  way  the  demon- 
stration of  filaria  (Fig.  142)  may  account  for  chyluria  or  elephantiasis.     If 


558  -\3IERIC.\X  PRACTICE  OF  SURGERY. 

we  find  the  picture  of  leukfemic  blood,  so  patent  to  the  merest  glance,  we 
maj^  often  be  warranted  m  excludbig  the  possible  diagnosis  of  lympho-sarcoma 
or  of  tuberculous  or  sj'philitic  Ij-mphadenitis  (Plate  II.,  Figs.  1  and  3).  The 
presence  of  megaloblasts  and  normoblasts,  in  combination  with  an  appreciable 
diminution  in  the  number  of  red  cells  and  a  relatively  high  haemoglobin  index, 
maj',  in  a  case  in  which  the  other  aspects  seem  to  point  rather  to  a  gastric  or  an 
intestinal  neoplasm,  indicate  a  primary  pernicious  ansemia  (Plate  IV.,  Fig.  2). 
Probably,  however,  the  information  afforded  by  a  determination  of  the  htemoglo- 
bin  percentage,  b}'  a  count  of  the  red  blood  cells,  and  by  an  examination  of  the 
condition  of  these  cells,  is,  from  the  standpoint  of  general  surgerj%  the  most  im- 
portant of  all.  It  throws  light  upon  the  general  nutritive  conditions  of  the  body 
as  a  whole,  and  indicates  accurately  the  extent  and  the  din-ation  of  the  disease. 

Tlie  surgeon  should  not  content  himself  with  a  smgle  examination  of  the 
blood  or  even  with  a  few  such  examinations:  he  should — if  he  desires  to  throw 
light  upon  the  diagnosis  or  to  watch  intelligently  the  progress  of  the  disease — 
have  the  examinations  made  regularly  and  the  results  charted  in  the  same  man- 
ner as  are  the  pulse  and  body  temperatm'e. 

Of  especial  value  to  the  surgeon  is  that  part  of  the  examination  of  the  blood 
which  relates  to  the  counting  of  the  leucocytes.  By  this  means  it  is  generall}'^ 
possible  definitel}'  to  recognize  the  existence  of  a  deep-seated  inflammatory  proc- 
ess which  might  othei-wise  escape  detection.  Sepsis  and  general  as  well  as  local 
infections  are  also  manifested  by  the  same  procediu-e,  at  times  with  surprising 
accm'ac}'  (Plate  IV.,  Fig.  3).  The  absence  of  leucocytosis  is  also  of  verj^  great 
importance,  since  it  either  indicates  that  inflammatory  lesions  are  lacking  alto- 
gether or  demonstrates  the  overwhelming  \ii-ulence  of  some  infectious  process 
on  the  organism;  furthermore,  it  maj^  signify  some  special  type  of  inflammatory 
disease,  as  tuberculosis,  mfluenza,  or  tj-phoid,  in  which  conditions  the  leuco- 
cytes are  sometimes  subnormal  in  nmnber. 

Much  is  also  to  be  learned  from  a  study  of  the  types  of  leucocytes  present  in 
each  case,  and  in  either  hj'per-  or  hj^o-leucocytosis  differential  leucocyte  coimts 
should  be  made.  Thus,  the  diagnosis  of  honphatic  leuktemia  maj'  be  made  in 
large  part  from  a  relative  and  absolute  increase  in  the  lymphocytes.  Trichino- 
sis, hook-worm  (Plate  IV.,  Fig.  1,  and  Plate  II.,  Fig.  6),  and  some  other  vari- 
eties of  parasitic  disease  may  be  strongly  suggested  bj'  proportionate  increase  m 
the  eosinophilic  white  cells,  which,  it  should  be  remembered,  are  also  increased 
in  certain  forms  of  bone  disease,  notably  in  involvement  of  the  marrow  by  some 
form  of  new  growth.  Relative  increase  of  the  polynuclear  neutrophiles  with 
leucocj-tosis  Is  indicative  of  inflammatory  disease,  ordinarily  of  bacterial  origin, 
and  no  leucocytosis  .should  be  taken  as  confirmatory  of  inflammation  vmless  it 
be  of  this  variety  (Plate  IV.,  Fig.  3). 

Tlie  clinician  must  always  bear  in  mind  the  frequent  exceptions  which  are 
encountered  in  connection  with  leucocytosis.    Thus,  even  large  pus  accumiila- 


EXPLANATION   OF   PLATE   HI. 

(Preparations  Stained  by  Goldliorn's  Polychrome  Methylene  Blue.) 

Fig.  1. — Cachectic  Ansemia,  from  a  Case  of  Uterine  Carcinoma.  The  severity  of  the  ansemia  is 
shown  hy  the  decrease  in  number  of  the  red  corpuscles,  their  diminution  in  size  (microcytosis),  and 
poiIdloc>^osis.  Most  of  the  cells  show  a  high  color  index,  causing  the  condition  somewhat  to  resemble 
that  seen  in  pernicious  anaemia.  A  single  myelocyte  is  present  in  this  field,  as  is  frequently  the  case 
in  anaemia  from  malignant  neoplasms.  Hiemoglobin,  50%;  red  corpuscles,  1,430,000;  leucocytes, 
7,300. 

Fig.  2. — Severe  Secondary  Ansemia  due  to  jEstivo-autumnal  Malarial  Infection.  The  infection 
was  contracted  in  Porto  Rico  during  1S98,  and  resulted  in  death  shortly  after  the  patient's  return  to 
this  country-. 

The  severity  of  the  infection  is  indicated  hy  the  number  of  invaded  corpuscles  seen  in  the  single 
field.  Five  cells  show  smaU  "ring-form"  jjarasites;  in  one,  two  plasmodia  are  present.  A  single  extra- 
cellular organism,  a  "crescent,"  is  shown.  The  marked  endoglobular  degeneration  of  even  the  unin- 
fected red  cells  is  weU  indicated  in  the  figure. 

Fig.  3. — Double  Tertian  Malarial  Infection.  The  double  character  of  the  infection  is  shown  by 
the  presence  of  two  parasites  nearing  segmentation,  and  two  relatively  young  forms.  Paroxysms  were 
quotidian  in  character.  The  blood  also  shows  a  moderate  degree  of  secondary  anemia,  indicated  by 
poikilocytosis  and  low  color  index. 


AMERICATC  PRACTICE  OF  SURGERY. 


PLATE   III 


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.ith.  Anst.  v.  E.  A.  Panke,  Leipzig. 


Plate    Illustrating  Various   Blood  Lesiorus 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  55& 

tions,  if  of  long  standing  or  well  encapsulated,  may  cause  slight  or  no  increase 
in  the  leucocytes,  while  occasionally  very  slight  infections,  as  small  boils, 
may,  in  particularly  susceptible  patients,  cause  a  pronounced  leucocytosis.  In 
no  important  case  should  the  surgeon  be  content  with  a  single  count,  but  sev- 
eral should  be  made  and  at  different  periods,  so  that  technical  errors  and  physio- 
logical conditions  may  not  confuse  the  symptom. 

Perhaps  it  is  also  well  to  point  out  the  possibility  of  over-valuing  leucocytosis 
as  a  sign  in  diagnosis.  The  surgeon  may  easily  be  led  to  draw  wrong  inferences 
if  he  fails  to  remember  that  leucocytosis,  even  of  considerable  degree,  may  exist 
as  a  physiological  phenomenon,  and  that  it  may  also  follow  the  use  of  certain 
drugs,  as  phloridzin. 

When  there  are  found,  in  the  blood,  leucocytes  the  cytoplasm  of  which  con- 
tains glycogenic  granules  that  assume  a  dark-brown  color  when  brought  in  con- 
tact with  a  solution  of  iodine  (a  condition  to  which  the  term  "iodophilia"  is 
often  applied),  we  may  interpret  this  circumstance  as  indicating  quite  accu- 
rately that  pus  has  formed  somewhere  in  the  body.  On  the  other  hand,  it  is  not 
safe  to  infer  that  the  absence  of  leucocytes  of  the  variety  we  have  just  described 
may  be  taken  as  an  evidence  that  pus  has  not  formed  in  any  part  of  the  body. 
It  must  also  be  remembered  that  diffuse  amyloid  degeneration,  such  as  is  observed 
particularly  in  syphilis  and  in  tuberculous  or  chronic  inflammatory  disease  of 
bone,  is  likely  to  be  characterized  by  the  presence,  in  the  blood,  of  these  same 
leucocytes.  When  the  iodophilia  is  found  to  be  progressive  w-e  are  warranted, 
I  believe,  in  drawing  the  inference  that  the  suppuration  is  also  on  the  increase. 

The  relation  of  the  blood  plates  to  surgical  diseases  I  believe  to  be  very  in- 
definite and  uncertain.  An  increase  in  the  number  of  the  platelets  is  taken  by 
some  as  indicative  of  a  tendency  to  rapid  clot  formation.  A  few  authors  think 
that  these  bodies  are  actively  concerned  in  the  thrombosis  so  frequent  in  certain 
diseases,  particularly  in  pneumonia  and  typhoid.  A  close  study  of  a  large  series 
of  cases  in  regard  to  this  point  durmg  the  past  two  years  has  fully  convinced  me 
that  there  is  no  relationship  betw^een  the  number  of  blood  plates  and  the  tend- 
ency to  thrombosis  or  rapid  clot  formation. 

Bacterial  examination  of  the  blood  is  resorted  to  more  and  more  frequently 
in  cases  in  which  there  is  question  as  to  general  hsemic  infection,  and  its  great 
utility  cannot  be  overestimated.  It  sometimes  affords  the  only  means  at  our 
disposal  for  demonstrating  what  particular  bacterial  agents  are  concerned  in  any 
general  and  in  certain  local  infectious  processes.  It  should  be  generally  under- 
stood that  the  amount  of  blood  required  for  a  satisfactory  examination  should 
be  relatively  large,  that  the  amount  of  the  media  into  which  the  blood  is  to  be 
inoculated  should  be  abundant,  and,  finally,  that  several  kinds  of  pabulum 
should  be  used,  particularly  such  as  most  closely  approximate  the  human  serum. 
Negative  results  in  these  examinations  are  not  to  be  given  too  much  considera- 
tion in  diagnosis,  on  account  of  the  great  possibility  of  technical  errors.    Posi- 


560  AMERICAN  PRACTICE  OF  Sl^RGERY. 

tive  findings  are  of  the  most  definite  character  possible,  and  in  a  good  many  in- 
stances this  demonstration  of  tlie  etiological  factor  of  the  disease  shapes  not  only 
the  diagnosis,  but  also  the  treatment  and  the  prognosis. 

Kryoscopy  of  the  blood  is  as  yet  ordinarily  but  little  employed  in  general 
surgical  diagnosis  or  study,  though  its  findings  are  occasionally  of  great  worth 
in  special  surgery,  particularly  in  diseases  of  the  kidnej^  or  in  cases  in  which 
transudates  are  formed.  Kryoscopy  of  the  urine  or  of  the  transudates  or  exu- 
dates is  of  little  utility  unless  compared  with  the  basis  furnished  by  the  same 
method  applied  to  the  blood.  When  this  method  is  employed  for  the  blood 
alone  it  does  not  appear  to  furnish  as  trustworthy  results  as  are  supplied  by 
other  and  better-established  methods. 

The  determination  of  the  alkalinity  of  the  blood,  though  often  of  interest  and 
value  to  the  internist,  particularly  in  such  conditions  as  diabetes  or  in  the  severe 
anajmias,  has  thus  far,  in  my  hands,  proven  of  little  value  as  an  assistance  in 
surgical  diagnosis. 

The  more  unusual  methods  of  examining  the  blood — such,  for  example,  as 
those  for  determining  the  total  percentage  of  iron  and  the  specific  gravity — have 
thus  far  proved  of  little  use.  This  is  doubtless  largely  due  to  the  facts  that  the 
technical  details  are  somewhat  complicated  and  consume  considerable  time,  and 
that  we  do  not  yet  possess  sufficient  physiological  data  on  which  to  base  our 
clinical  studies.  There  can  be  no  question  that,  as  the  normal  chemistry  of  the 
blood  becomes  more  thoroughly  elucidated,  the  pathological  chemistry  will  keep 
pace  and  will  finally  yield  results  probably  more  valuable  even  than  are  supplied 
by  our  now  largely  morphological  studies.  The  very  suggestive  work  on  the 
psonins,  toxins,  and  antitoxins  promises  much  for  future  research  along  these  lines. 

The  serum  reactions  which  are  based  on  the  formation  of  specific  anti-bodies 
in  the  blood  under  the  influence  of  specific  infections  or  toxEemias,  while  they 
are  more  commonly  employed  in  medical  conditions,  also  lend  themselves  to 
surgical  diagnosis  with  equally  beneficial  results.  The  most  important,  to  the 
surgeon,  of  these  agglutinative  or  serum  reactions  are  those  which  are  observed 
in  typhoid  fever  and  tropical  dysentery,  both  of  which,  when  the  technical  de- 
tails are  carried  out  with  proper  care,  and  when  positive  results  are  secured,  are 
definitely  instructive  signs  of  great  utility.  On  the  other  hand,  they  are  nearly 
worthless  when  only  negative  results  are  obtained. 

THE   CEREBRO-SPINAL   FLUID. 

The  technique  of  lumbar  puncture  is  so  simple,  and  the  evidence  furnished 
by  analysis  of  the  cerebro-spinal  fluid  often  so  valuable,  that  it  should  be  con- 
stantly employed  in  the  differential  diagnosis  of  surgical  diseases  of  the  brain 
and  cord.  By  the  relief  of  intracranial  and  spinal  pressure  it  also  becomes  oc- 
casionally a  measure  of  considerable  therapeutic  value.  Differential  diagnosis 
between  ursemia  and  meningitis,  frequently  so  diflScult,  is  occasionally  rendered 


EXPLANATION  OF    PLATE   IV. 

(Preparations  Stained  by  Goldhorn's  Polychrome  Methylene  Blue.) 

Fig.  1. — Blood  Smear  from  a  Case  of  Trichinosis.  The  eosinophilic  leucocytes  arc  markedly  in- 
creased in  number,  both  relatively  (14%)  and  absolutely.  The  red  corpuscles  show  some  diminution 
ill  hsemoglobin  staining  and  a  few  microcytes  are  present,  but  the  ancemia  at  this  stage  of  the  infection 
was  not  a  marked  feature  of  the  case.  The  condition  was  accidentally  discovered  in  the  course  of 
routine  examinations  of  the  blood  in  a  surgical  ward. 

Fig.  2.— Pernicious  Anaemia.     The  case  was  originally  supposed  to  be  one  of  gastric  carcinoma. 

The  red  corpuscles  are  few  in  number,  but  their  hcemoglobin  index  is  high  above  normal,  a  condi- 
tion quite  characteristic  of  pernicious  anaemia.  Marked  poikilocytosis  is  present  and  microcytes  and 
macrocytes  exceed  normal-sized  red  corpuscles  in  number.  Polychromatopliilic  degeneration  is  marked 
in  some  of  the  cells,  and  both  normoblasts  and  megaloblasts  are  present  in  considerable  numbers.  One 
of  the  latter  cells  shows  karyokinetic  changes  in  its  nucleus.  Megaloblasts  arc  more  or  less  diagnostic 
of  pernicious  anjemia,  though  also  occasionally  fotmd  in  cachectic  ana-mias. 

Fig.  3. — Polynuclear  neutrophilic  leucocytosis  (32,000  Leucocytes  per  c.mm.),  Occurring  in  an 
Acute  Attack  of  Appendicitis  in  a  Chlorotic  girl. 

The  relatively  high  number  of  polj'-nuclcar  leucocytes  is  well  shown  in  this  typical  field.  The 
chlorosis  is  indicated  by  the  low  haemoglobin  index,  low  red-cell  count,  and  poikilocytosis. 


AMERICAN  PRACTICE  OF  SURGERT. 


PLATE  IV 


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Harlow  Brooks   Del 


Lith.  Ani:t.  V.  E.  A.  Funke,  Leipzig. 


Plate    Illustratinf  Various   Blood  Lesions 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  561 

easy  by  this  pieans.  Ventricular  hemorrhage  may,  in  a  certain  number  of  cases, 
be  differentiated  from  subdural  hemorrhage  by  the  fact  that  the  fluid  withdrawn 
is  diffusely  blood-stained,  whereas  in  the  latter  condition  the  cerebro-spinal  fluid 
is  generally  clear. 

Inflammatory  conditions  of  the  meninges  are  indicated  by  a  turbid,  purulent 
fluid  which  clots  readily,  while  the  formed  elements  present  are  chiefly  desqua- 
mated endothelial  cells  and  polynuclear  leucocytes  or  pus  cells.  In  tuberculous 
disease,  however,  clot  formation  is  usually  but  slightly  marked,  the  fluid  is  more 
clear,  and  lymphocytes  commonly  predominate  in  its  sediments.  The  cerebro- 
spinal fluid  may  also  furnish  most  important  aid  in  establishing  the  differential 
diagnosis  between  localized  cerebral  abscess  or  thrombosis  and  diffuse  menin- 
gitis. 

In  certain  specific  inflammatory  diseases  of  the  meninges,  as  in  epidemic 
cerebro-spinal  meningitis  or,  more  rarely,  in  tuberculous  meningitis,  it  is  pos- 
sible to  demonstrate,  either  by  means  of  smear  cultures  or  by  animal  inocula- 
tion, the  specific  cause  of  the  disease, — frequently  a  matter  of  the  greatest 
importance. 

Although  lumbar  puncture  is  stated  by  most  authors  to  be  absolutely  with- 
out danger,  too  rapid  or  too  complete  removal  of  the  fluid  may  occasionally 
cause  immediate  collapse  and  death.  Although  surgeons  need  no  warning  as  to 
the  danger  of  infection  of  the  cerebro-spinal  space  by  careless  methods,  this 
possibility  should  always  be  held  in  mind. 

THE  SECRETIONS. 
In  our  discussion  of  the  different  secretions  we  shall  consider  only  those 
alterations  which  throw  light  upon  certain  diseased  conditions  of  the  body,  or 
which  modify  these  several  fluids. 

The  Saliva. 

An  increase  m  the  amount  of  the  saliva  may  indicate  mercurial,  iodide,  or 
other  mineral  poisoning,  the  specific  kind  of  which  can  be  easily  determined  by 
chemical  methods.  Decrease  in  the  amount  may  also  signify  poisoning,  as  from 
atropine,  or  it  may  indicate  that  one  or  more  of  the  salivary  ducts  is  occluded, 
as  by  a  calculus.  Chemical  examination  of  the  saliva  is  frequently  resorted  to 
for  the  determination  of  the  rate  of  gastric  or  intestinal  absorption.  One  of  the 
iodides  or  some  one  of  tlie  drugs  which  are  excreted  by  the  saliva  is  administered, 
and  the  time  which  elapses  before  it  appears  in  this  secretion  measures  quite  ac- 
curately the  rapidity  of  absorption.  The  determination  of  the  digestive  action 
is  rarely  necessary  in  surgery,  but  may  be  utilized  in  appropriate  cases. 

Tubercle  bacilli,  actinomyces,  gonococci,  diphtheria  bacilli,  and  other  spe- 
cific micro-organisms  may  be  found  in  the  saliva,  either  as  contaminations  from 
diseased  foci  in  the  buccal  cavity  or  as  an  evidence  of  a  diseased  state  of  the 


562  AMERICAN  PRACTICE   OF  SURGERY. 

salivary  glands.  Pus  cells,  blood,  and  desquamated  epithelium  may  be  dis- 
charged from  the  duct  of  an  infected  gland,  and  the  finding  of  these  products 
may  furnish  the  first  indication  that  any  such  disease  exists. 

The  Gastric  Juice. 

An  examination  of  the  contents  of  the  stomach  is  often  of  the  greatest  pos- 
sible assistance  in  surgical  diagnosis,  and  therefore  it  should  never  be  omitted  in 
cases  in  which  some  organic  disease  of  that  viscus  is  suspected.  Where  vomitus 
is  not  available,  a  test  meal  should  be  ordered,  and  after  a  definite  time  the  con- 
tents of  the  stomach  should  be  removed  through  the  tube  and  submitted  to  both 
morphological  and  chemical  analysis.  In  surgery  and  medicine  alike  probably 
the  most  important  single  investigation  in  connection  with  the  gastric  secretion 
is  the  determination  of  free  hydrochloric  acid.  The  diminution  in  quantity  or 
the  absence  of  this  acid,  when  the  condition  is  found  to  persist,  is  strongly  sug- 
gestive of  gastric  carcinoma,  particularly  when  deficiency  in  free  hydrochloric 
acid  is  associated  with  the  presence  of  lactic  acid.  The  presence  of  free  hydro- 
chloric acid  by  no  means  excludes  the  diagnosis  of  carcinoma  of  the  stomach, 
since  it  is  often  found  present,  even  in  normal  amounts,  particularly  when  the 
cardiac  extremity  of  the  stomach  is  largely  intact.  It  is  a  noteworthy  fact  that 
free  hydrochloric  acid  is  rather  more  commonly  found  in  sarcoma  than  in  cancer 
of  the  stomach.  The  diagnosis  of  carcinoma  of  the  stomach  is  further  corrobo- 
rated by  the  presence  of  broken-down  blood  in  the  fluid  contents  of  this  organ. 
Occasionally  particles  of  new  growth  may  be  found  in  the  fluid,  and,  on  being 
submitted  to  microscopic  examination,  they  may  definitely  establish  the  diag- 
nosis. On  the  other  hand,  when  blood  is  found  associated  with  abundant  free 
hydrochloric  acid,  this  circumstance  is  considered  indicative  rather  of  ulceration 
than  of  a  cancer.  As  a  rule,  lactic  acid  is  absent  in  cases  of  simple  ulceration; 
when  it  is  present  it  is  generally  found  in  cases  of  pyloric  ulcer,  in  which  affec- 
tion there  is  apt  to  be  gastric  dilatation  with  more  or  less  fermentation  of  the 
food. 

An  interesting  and  often  highly  instructive  test  is  that  which  consists  in 
administering  to  the  patient  a  measured  amount  of  food  or  drink,  and  then, 
after  a  definite  period  of  time  has  elapsed,  withdrawing  it  for  examination.  In 
this  way  the  peptic  capabilities  of  the  stomach  and  the  degree  of  pyloric  perme- 
ability may  be  ascertained.  It  is  also  an  easy  matter,  in  cases  of  dilatation,  to 
determine,  by  actual  measurement  of  the  fluid  contents  of  the  stomach,  just 
how  far  the  distention  of  the  organ  has  progressed. 

The  finding  of  certain  forms  of  bacteria  in  the  stomach  may  be  of  diagnostic 
import;  nevertheless,  too  much  reliance  should  not  be  placed  upon  such  evi- 
dence, since  the  presence  of  bacteria  is  largely  determined  by  the  food.  In  my 
experience  the  occurrence  of  the  Boaz-Oppler  bacillus  is  of  no  value  in  the  diag- 
nosis of  cancer  of  the  stomach. 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  563 

The  discovery  of  pus  in  any  considerable  amount  is  much  more  suggestive  of 
some  extraneous  suppuration  draining  into  the  stomach  than  of  a  suppurative 
gastritis.  In  these  cases  the  pus  should  always  be  carefully  studied,  in  the  hope 
that  it  may  contain  cells  or  organisms  which  by  their  character  indicate  the 
origin  and  location  of  the  primary  suppuration. 

Indol,  skatol,  bile,  or  even  simple  fecal  odor  may  assist  materially  in  the  diag- 
nosis of  ileus,  while  parasites  and  their  ova  are  by  no  means  uncommonly  found 
in  the  gastric  contents,  either  indicating  infection  from  the  gut  or  parasitic  dis- 
ease of  the  stomach  itself. 

The  Nasal  Secretion. 

Study  of  the  nasal  secretion  is  often  of  considerable  value,  particularly  in  in- 
fectious diseases,  such  as  diphtheria,  tuberculosis,  or  cerebro-spinal  meningitis. 
The  clinician  must,  however,  remember  that  pathogenic  bacteria,  notably 
meningococci,  diphtheria  bacilli,  and  pneumococci,  may  exist  in  the  nasal  pas- 
sages without  disease  necessarily  taking  place,  although  in  these  cases  even 
slight  traumatisms  to  the  nasal  mucosa  may  be  followed  by  serious  infection, 
such  as  probably  takes  place  in  the  development  of  epidemic  cerebro-spinal 
meningitis.  When  pus  is  found  in  any  considerable  amoimt,  its  point  of  origin 
should  be  determined.  A  good  deal  of  pus  may  originate  from  inflammation  of 
the  mucosa  only,  in  which  case  the  exudate  is  very  apt  to  be  chara,cterized  by 
the  presence  of  a  good  many  eosinophile  cells;  but  large  amounts  of  pus  are 
much  more  likely  to  be  due  to  suppuration  of  the  antrum. 

Where  nasal  growths  exist  the  number  of  epithelial  cells  in  the  secretion  may 
be  considerably  increased,  but.no  more  so  than  in  some  simple  catarrhal  proc- 
esses. 

Investigation  of  the  nasal  secretion  is  necessary  in  traumatic  injuries  of  the 
head ;  for  example,  in  fracture  of  the  base  of  the  skull,  when  cerebro-spinal  fluid 
may  be  found  escaping  from  the  nose.  This  fluid  may  be  recognized  by  its  non- 
albuminous  character  and  by  the  presence  of  a  substance  which  reduces  Feh- 
ling's  solution.  In  a  case  of  recent  fracture,  the  specimen  of  fluid  collected  is 
commonly  more  or  less  stained  with  blood,  but  in  certain  instances  of  cerebral 
tumor,  and  also  in  some  cases  of  hydrocephalus,  cerebro-spinal  fluid  may  be 
found  escaping  from  the  nose,  often  in  such  quantities  as  to  cause  great  annoy- 
ance to  the  patient.  In  cases  of  this  nature  the  fluid  is,  of  course,  ordinarily  free 
from  blood,  except  such  as  may  enter  from  the  nasal  mucosa,  which  is  also  likely 
to  contribute  the  mucus,  leucocytes,  and  desquamated  epithelium  normal  to  the 
nasal  secretion. 

The  Sputum. 

The  sputum,  which  normally  consists  chiefly  of  the  secretions  of  the  tracheal 
and  bronchial  glands,  often  well  repays  study,  though  to  a  much  less  degree  in 
surgery  than  in  internal  medicine. 


564 


AMERICAN   PRACTICE   OF   SURGERY. 


Tubercle  bacilli,  pneumococci,  actinomyccs,  and  other  specific  organisms  in 
the  sputum  are  of  great  significance,  while  cells  and  j^articles  of  tissue  from  pul- 
monary tumors  may  be  discharged  in  the  same  manner,  thus  materially  assist- 
ing diagnosis.  In  nearly  all  cases  of  inflannnatory  disease  of  the  respiratory 
tract,  blood  cells,  fibrin,  leucocytes,  and  pus  are  present  to  a  greater  or  less  de- 
gree, and  are  often  indicative  of  the  character,  extent,  and  standing  of  the  focus 


Fig.  143. — Echinococcus.     Embryos  and  liooklets  discharged  in  the  spiitu 
cyst  of  tlie  hmg. 


I  from  a  case  of  hydatid 


from  which  they  arise.  Pus,  sometimes  mixed  with  hepatic  cells,  may  be  dis- 
charged through  the  sputiun  from  a  liver  abscess,  which  not  uncommonly  bursts 
into  the  lung;  in  the  same  manner  echinococcus  booklets,  nodules  of  actinomy- 
cotic material,  etc.,  may  be  discharged  (Fig.  143). 

In  gangrene  of  the  lung  or  in  extensive  tuberculosis  considerable  masses  of 
pulmonary  tissue  may  be  expectorated,  and  may  be  of  such  character  as  to  de- 
mand microscopic  examination  for  their  definite  recognition. 


The  Mammary  Secretion. 

In  most  surgical  diseases  affecting  the  mammary  gland  when  functionally  in- 
active, examination  of  the  secretion,  as  a  rule,  shows  little  of  direct  value.  On 
account  of  the  superficial  location  of  the  gland,  which  renders  its  physical  ex- 
amination relativelj^  easy,  studies  of  the  secretion  are  not  generally  necessary. 
Nevertheless,  at  times  they  become  highly  valuable.  Sufficient  secretion  may, 
in  certain  conditions,  be  expressed  from  the  nipple  or  gland  to  give  on  examina- 
tion a  fairly  certain  knowledge  of  the  changes  which  are  taking  place.  Blood  or 
pus  may  indicate  the  formation  of  an  abscess,  and  the  bacteria  found  in  the  se- 
cretion may  show  its  cause.  In  the  by  no  means  rare  cases  of  mammary  tuber- 
culosis, tubercle  bacilli  are  not,  as  a  rule,  demonstrable  in  the  secretion.     In 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  565 

certain  tumors  of  tlie  breast,  particularly  adenomata,  cells  and  secretions  more 
or  less  characteristic  of  the  growth  may  be  discharged. 

Examination  of  the  secretion  during  lactation  is  rarely  necessary  in  surgery; 
at  most,  it  may  be  thought  desirable  in  a  case  in  which  suppuration  or  a  neo- 
plasm is  suspected.  The  variation  in  the  quantity  or  quality  of  the  milk  in  sur- 
gical disease  may,  however,  become  of  importance,  since  in  so  many  conditions;, 
such  as  shock,  the  amount  becomes  diminished  or  the  character  changed. 

Secretions  of  the  Female  Genital  Tract. 

In  many  conditions  affecting  the  female  genital  tract,  and  particularly  in  the 
infectious  diseases  which  so  commonly  affect  these  parts,  systematic  study  of 
the  secretions  becomes  a  matter  of  necessity.  Not  only  should  all  abnormal 
discharges  receive  attention,  but  the  apparently  normal  secretion  of  each  glan- 
dular distribution  should  be  investigated.  Thus,  gonorrhoeal  affection  of  the 
vulvo-vaginal  glands  may  exist  without  vaginal  infection  and  vaginal  infection 
without  cervical  involvement.  The  results  attending  these  examinations  may 
be  somewhat  confusing,  unless  one  bears  thoroughly  in  mind  the  character  and 
great  variation  of  the  secretions  normal  to  these  parts.  Thus,  the  vaginal  secre- 
tion, in  addition  to  leucocytes  and  desquamated  epithelium  normally  derived 
from  its  own  wall,  is  almost  invariably  more  or  less  composed  of  materials  from 
the  endometrium  of  the  uterus  and  cervix.  Just  before,  during,  and  for  a  con- 
siderable time  after  menstruation,  blood,  broken-down  epithelium,  leucocytes, 
and  frequently  more  or  less  pus  are  present  in  the  discharge ;  but  such  material 
found  unassociated  with  menstruation  would  be  strongly  suggestive  of  endo- 
metritis or  even  of  a  new-growth  of  the  uterus. 

Similarly,  the  desquamated  epithelium  naturally  present  in  the  vaginal  se- 
cretion may  be  confused  with  products  due  to  the  erosion  of  a  tumor.  In  every 
case  of  purulent  discharge  from  the  genital  tract  the  material  should  be  espe- 
cially examined  for  the  bacteria  present.  Gonococci,  tubercle  bacilli,  and  mem- 
bers of  the  proteus  group  of  bacteria  can,  as  a  general  rule,  be  satisfactorily  rec- 
ognized— at  least  so  far  as  it  is  necessary  to  do  so  for  clinical  purposes — by  the 
examination  of  smears  alone.  Wherever  it  is  deemed  of  great  import  that  the 
precise  character  of  any  inflammatory  process  be  decided,  bacterial  cultures 
should  be  made;  this  is  often  of  great  value,  particularly  in  post-partum  infec- 
tions. Before  a  final  negative  conclusion  is  reached  in  any  case  of  infection, 
several  examinations  should  be  made. 

Occasionally  there  are  found,  in  the  matter  discharged  from  the  uterus,  por- 
tions of  tissue,  the  examination  of  which  may  definitely  decide  the  important 
question  between  some  form  of  tumor  of  the  endometrium  and  the  products  of 
inflammation  or  conception.  I  have  found  it  in  all  cases  much  the  safest  pro- 
cedure not  to  rely  on  gross  or  direct  microscopic  examination  only  of  this  fresh 
material,  but  to  prepare  and  examine  it  after  the  usual  histological  methods. 


566  AJIERICAN  PRACTICE  OF  SURGERY. 

Unless  this  course  be  adopted  as  a  rule,  serious  diagnostic  mistakes  will  inevi- 
tably occur. 

An  examination  of  the  vaginal  secretion  sometimes  reveals  the  presence  of 
parasites  or  their  ova,  of  which  the  thread-worm  and  the  Trichomonas  vaginalis 
are  probably  the  ones  most  frequently  met  with.  It  is  needless  to  say  that  an 
absolute  diagnosis  of  disease  of  the  genital  tract  of  the  female  should  never  be 
made  on  the  examination  of  the  secretions  alone;  this  should  be  but  supple- 
mentary to  as  complete  a  physical  examination  as  is  practicable  in  any  particu- 
lar case.  "WTiere  growths  or  swellings  suggestive  of  sj^philitic  infection  are 
present,  the  secretions  from  them,  or,  if  necessary,  expressed  blood  or  serum, 
should  be  searched  for  the  Spirocha?ta  pallida,  since  it  now  appears  that  this 
organism  is  quite  constantly  associated  with  recent  syphilitic  lesions. 

Secretions  of  the  Male  Genital  Tract. 

In  diseases  of  the  genito-urinary  tract  of  the  male  the  urethral  secretions 
should  be  investigated;  early  examination  frequently  establishes  the  diagnosis, 
for  example,  of  a  gonorrhoeal  urethritis,  before  the  clinical  symptoms  have  de- 
veloped. Streptococcus,  pneumococcus,  and  other  infections  may  be  detected 
in  the  same  manner,  as  may  also  tuberculous  disease.  As  regards  the  tubercle 
bacillus  the  differentiation  from  the  other  acid-fast  bacilli  should  be  made  cer- 
tain, if  necessary,  by  animal  inoculation. 

Where  prostatic  disease  is  in  question,  the  secretion  from  the  prostate  maj^ 
be  readily  obtained  by  first  causing  the  patient  to  urinate  or  by  othernase  wash- 
ing out  the  urethra,  after  which  massage  of  the  prostate  and  seminal  vesicles 
drives  the  secretions  from  these  glands  into  the  urethra,  from  which  locality 
they  may  be  secured  for  examination.  Gonorrhoeal,  tuberculous,  and  other  in- 
fectious processes  are  readily  detected  in  this  manner.  In  cases  ui  which  syph- 
ilitic infection  is  suspected,  a  search  for  Spirochsetse  pallidae  should  be  made. 

When  lesions  of  the  testis  or  epididymis  ai'e  present,  much  may  be  learned 
by  an  examination  of  the  seminal  secretion.  Pus  and  blood  in  more  than  minute 
amounts  may  indicate  inflammatory  disease;  or  blood  alone,  a  new-growth. 
The  demonstration  of  bacteria  in  the  secretion  may  absolutely  decide  the  na- 
ture of  the  process,  and  the  presence  or  absence,  character,  and  motility  of  the 
spermatozoa  may  throw  m.uch  light  on  the  true  character  of  the  lesion.  The 
permeability  of  the  epididymis  and  of  the  vas  deferens  may  also  be  determined 
by  such  an  examination  of  the  secretion  in  the  urethra,  and  the  siu'geon  is  now 
and  then  surprised  at  the  considerable  number  of  cases  in  which  few  or  no 
spermatozoa  reach  the  urethra.  A  discovery  of  this  nature  serves,  in  not  a  few 
cases,  to  determine  the  proper  course  of  surgical  treatment.  Surgeons  are  too 
apt  to  neglect  this  very  simple  and  often  decisive  method  of  examination,  even 
in  those  cases  in  which  it  is  perfectly  practicable  to  secure  the  secretion  for 
investigation. 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  567 

Other  Secretions. 

In  the  various  bacterial  diseases  of  the  eye  the  lachr^inal  secretion  may  fur- 
nish evidence  of  the  specific  type  of  infection  of  the  conjunctiva  or  of  its  adja- 
cent glands  and  mucous  tracts.  In  exploratory  procedures  it  is  occasionally 
possible  to  secure  the  secretions  from  the  internal  viscera,  as  that  of  the  pan- 
creas or  liver,  and  thus  the  surgeon  may  obtain  direct  evidence  of  changes  tak- 
ing place  in  these  organs.  In  short,  all  of  the  secretions  may,  under  diseased 
conditions,  contribute  facts  which  have  an  important  bearing  upon  surgical 
diagnosis,  not  only  in  cases  of  local  disease,  but  also  in  those  of  a  more  general 
nature. 

THE   EXCRETIONS. 

The  Urine. 

Examination  of  the  urine  plays  a  large  part  in  the  diagnosis  and  study  of 
nearly  all  disorders  of  the  body.  Its  importance,  however,  is  greater  in  the  do- 
main of  internal  medicine  than  in  that  of  surgery.  Its  chief  value,  in  the  latter 
domain,  is  to  be  found  in  the  special  surgery  of  the  urinary  organs. 

One  point  of  great  importance  in  connection  with  the  exammation  of  the 
urine — a  point  which  has  but  recently  received  adequate  attention — is  that  the 
amount  and  character  of  the  food,  drink,  and  medication  have  a  most  direct 
and  important  bearing  on  the  urinary  picture.  An  examination  of  the  urine 
should,  therefore,  be  prefaced  by  a  close  inquiry  into  this  important  question, 
so  that  the  urinary  findings  may  not  be  incorrectly  interpreted.  Thus,  for  ex- 
ample, the  amount  of  water  taken  as  food  or  drink,  and  the  quantity  excreted 
by  the  skin,  respiration,  and  bowel  determine  to  a  large  extent  the  color,  reac- 
tion, and  specific  gravity  of  the  urine.  Articles  of  food,  such  as  rhubarb  and 
asparagus,  and  even  excessive  amounts  of  albumin  or  sugars,  or  drugs,  such  as 
phloridzin,  may  cause  marked  and  apparently  serious  alterations  in  the  color, 
odor,  and  chemical  nature  of  the  urine. 

Another  frequent  source  of  error  lies  in  the  manner  in  which  the  specimen 
is  collected,  and  it  should  always  be  borne  m  mind  that  the  urine  may  be  con- 
taminated by  substances  derived  from  the  bladder,  prostate,  and  urethra;  or  by 
materials  entering  the  urine  from  the  external  genitals,  the  rectum,  or  the  va- 
gina in  women;  from  the  air,  or  from  the  vessel  into  which  the  specimen  is 
voided.  Substances  foimd  in  the  urine,  particularly  when  of  imusual  nature, 
should  never  be  considered  as  of  clinical  significance  until  all  these  possibilities 
of  contamination,  which  may  even  be  wilfully  effected,  have  been  considered 
and  excluded. 

Ureteral  catheterization  has  furnished  us  with  the  means  of  determining  ac- 
curately the  condition  of  each  one  of  the  kidneys  separately,  and,  since  it  has 
been  shown  that  under  normal  conditions  both,  organs  excrete  alike,  we  can  now 


568  AMERICAN  PRACTICE  OF  SURGERY. 

definitely  decide  whether  one  or  both  are  involved  in  any  disease  process,  and 
to  a  certain  extent  we  may  also  conclude  as  to  the  relative  extent  of  the  disease. 
This  precaution  is  of  particular  bearing  on  cases  in  which  operative  measures  on 
one  or  both  kidneys  are  contemplated. 

As  already  intimated,  the  amount,  color,  reaction,  and  specific  gravity  of  the 
urine  are  to  be  considered  in  connection  with  the  amount  of  fluid  ingested  as 
well  as  with  that  excreted  elsewhere.  When  these  do  not  appear  to  be  normally 
balanced,  there  is  reason  to  suspect  the  existence  of  disease.  The  precise  nature 
of  the  disorder  must  be  determined  by  further  investigation,  which  demands 
examination  of  the  urinary  excretion  for  the  entire  twenty-four  hours,  after  the 
patient  has  been  placed  upon  a  simple,  though  normal  and  easily  determined 
diet,  as  of  measured  amounts  of  bread,  milk,  and  lean  meat. 

Much  more  valuable  data  for  the  estimation  of  these  points  is  to  be  derived 
from  kryoscopy  of  the  urine,  by  means  of  which  the  molecular  concentration 
may  be  determined  from  its  freezing-point.  For  the  proper  understanding  of 
this,  the  same  method  must  also  be  applied  to  the  blood  and  to  any  transudates 
which  may  be  present  in  the  case.  Any  discrepancy  between  the  normal  bal- 
ance— as,  for  example,  increased  concentration  of  the  blood  with  decrease  in  the 
molecular  concentration  of  the  urine — indicates  deficient  renal  activity. 

A  procedure  presenting  fewer  technical  difficulties  to  the  surgeon,  and  at  the 
same  time  giving  an  accurate  test  of  the  permeability  of  the  kidney,  is  afforded 
by  the  administration  of  phloridzin  or  methylene-blue  and  the  determination  of 
the  time  required  for  its  easily  recognized  appearance  in  the  urine.  Where  ure- 
teral catheterization  is  also  practised,  the  relative  activity  of  the  two  kidneys 
may  thus  be  ascertained. 

The  amount  of  urea  excreted  in  the  urine  is  rarely  of  much  importance  to  the 
surgeon  when  the  rate  of  permeability  of  the  kidney  has  already  been  demon- 
strated; but  when  the  amount  remains  high  in  the  presence  of  a  light  nitro- 
genous diet,  it  is  strongly  suggestive  of  tissue  destruction,  as  in  diabetes.  De- 
creasing excretion  of  urea  is  shown  in  such  conditions  as  Weil's  disease,  acute 
yellow  atrophy  of  the  liver,  and  in  some  cases  of  diffuse  carcinosis.  The  respec- 
tive amounts  of  urea  and  uric  acid  excreted  in  surgical  conditions  are  of  rela- 
tively great  importance  in  surgery,  on  account  of  the  diminished  solubility  of 
uric  acid  and  the  consequent  tendency  to  precipitation  and  calculus  formation, 
either  when  it  is  thrown  out  of  solution  in  the  kidney  on  account  of  increased 
excretion,  or  when  the  chemical  characteristics  of  the  urine  are  such  as  favor  its 
precipitation. 

Albuminuria  is  of  considerably  less  significance  in  surgery  than  in  medicine, 
except  for  that  which  takes  place  in  hsematuria  or  in  post-operative  cases.  Al- 
buminuria may  occur  in  surgical  shock,  after  operations,  particularly  where  ex- 
tensive manipulation  of  the  tissues  has  been  necessary,  after  injuries  to  the  head, 
in  carcinomatous  peritonitis,  in  abscess  of  the  liver,  and  in  nearly  all  the  diseases 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  569 

of  an  infectious  nature.  It  may  follow  the  administration  of  many  drugs,  no- 
tably those  of  an  irritant  nature,  or  may  occur  after  the  observance  of  a  certain 
diet — for  example,  the  ingestion  of  egg  albumin.  In  certain  cases  it  may  also 
appear  apparently  as  an  individual  peculiarity  without  demonstrable  disease  or 
other  cause.  The  occurrence  of  albumin  in  the  urine  in  surgical  disease  is  of 
great  importance  only  when  its  causation  is  of  a  serious  surgical  nature,  and 
albuminuria  per  se  is  no  longer  of  the  grave  significance  which  the  text-books  of 
a  few  years  ago  led  us  to  believe.  It  may  occur  apparently  without  any  connec- 
tion with  renal  lesions,  and,  conversely,  kidney  disease,  often  of  the  most  grave 
nature,  may  exist  without  albuminuria.  The  simple  presence  of  albumin  in  the 
urine,  where  renal  permeability  is  within  the  range  of  normal,  is  now  no  longer 
considered  as  contraindicating  operation  or  the  administration  of  a  general  an- 
aesthetic, though  its  cause  be  distinct  renal  disease.  Extra  percautions  in  the 
selection  and  use  of  the  anjesthetic  may,  however,  be  necessary.* 

When  albuminuria  occurs  as  a  manifestation  of  the  escape  of  blood  into  the 
urine  its  surgical  importance  is  great,  and  the  probable  point  of  entrance  of  the 
blood  must  be  ascertained,  as  well  as  the  cause.  Such  an  escape  of  blood  may 
occur  from  a  renal  or  cystic  neoplasm,  from  a  stone  located  in  the  kidney  itself, 
in  the  ureter,  or  in  the  urinary  bladder;  from  some  inflammatory  condition  or 
from  a  simple  congestion  of  the  kidney;  or,  finally,  from  some  traumatism  of 
the  bladder  or  urethra. 

Glycosuria  is  also  of  less  interest  in  surgery  than  in  general  medicine,  though 
its  occurrence  in  surgical  diseases  is  often  of  the  most  grave  significance,  both 
from  the  standpoint  of  diagnosis  and  from  that  of  surgical  therapeutics.  The 
wide  difference  between  simple  glycosuria  and  glycosuria  as  a  symptom  of  dia- 
betes mellitus  must  be  fully  appreciated,  since  the  former  condition  may  be  but 
a  temporary  one  and  due  perhaps  to  individual  peculiarities,  dietetic  conditions, 
or  the  use  of  certain  drugs,  as  phloridzin ;  while  the  latter  is  a  disease  in  which 
glycosuria  is  a  single  manifestation  and  in  which  gangrene,  delayed  healing,  and 
fatal  coma  are  notoriously  prone  to  occur.  Temporary  glycosuria  may  take 
place  in  injury  to  the  head  or  in  certain  cases  of  mental  or  physical  shock. 

Indican  is  a  product  of  albuminous  decomposition  which  occurs  in  the  urine 
in  the  case  of  excessive  putrefaction,  particularly  in  the  stomach  and  small  in- 
testine. Simon  asserts  that  its  presence  and  amount  are  of  diagnostic  impor- 
tance, since  it  is  found  particularly  in  cases  of  derangement  of  the  gastric  secre- 
tion or  of  the  motor  powers  of  the  small  intestine.  Its  appearance,  in  my  opinion, 
is  too  inconstant  and  indefinite  to  render  it  of  any  great  diagnostic  value. 

The  occurrence  of  bile  pigment  in  the  urine  takes  place  when  there  is  any 
obstruction  to  prevent  the  normal  flow  of  the  bile  into  the  intestine,  as  may  oc- 

*The  special  chemical  nature  of  the  albumin  excreted  is  often  more  or  less  diagnostic  as  to 
its  cause;  thus  Bence-Jones  albumin,  which  is  easily  recognized  by  its  special  reactions,  occurs 
\n  most  if  not  all  cases  of  multiple  myeloma. 


570  AMERICAN  PRACTICE  OF  SURGERY. 

cur  from  an  impacted  gall  stone,  from  catarrhal  swelling  of  the  mucosa  of  the 
duct,  or  from  the  pressure  of  a  neighboring  tumor  or  an  inflammatory  deposit. 
It  also  takes  place  whenever  from  any  cause  the  liver  is  unable  to  convert  the 
waste  blood  pigment  normally,  as  in  acute  yellow  atrophy  or  in  Weil's  disease, 
or  when  an  excessive  destruction  of  the  corpuscular  elements  of  the  blood  throws 
an  overabundant  supply  of  pigment  on  the  liver,  as  in  malaria,  pernicious  anae- 
mia, and  like  maladies.  Bile  in  the  urine  is  almost  always  associated  with  more 
or  less  jaundice,  so  that  its  diagnostic  value  is  ordinarily  only  corroborative  and 
necessitates  a  much  wider  investigation  for  the  determination  of  its  cause. 

The  estimation  of  the  chlorides  of  the  urine  is  not  of  much  value  in  surgery, 
except  as  a  means  of  showing  the  degree  of  absorption  from  the  gastro-intestinal 
canal.  They  are  decreased,  sometimes  very  markedly,  in  many  acute  infectious 
diseases,  notably  in  acute  inflammation  of  the  lung. 

The  phosphates  of  the  urine  are  also  of  relatively  little  importance,  except  as 
they  may  be  deposited  in  the  renal  pelvis  or  bladder,  and  so  tend  to  the  forma- 
tion of  stone.     They  are  much  augmented  in  extensive  tissue  destruction. 

Unquestionably  the  most  valuable  facts  derived  from  the  examination  of 
urine  in  surgery  are  those  secured  by  microscopical  study.  In  this  relation  care 
must  always  be  taken  not  to  interpret  incorrectly  certain  bodies  which  normally 
occur  in  the  urine ;  thus,  epithelial  cells  in  greater  or  less  numbers  are  naturally 
eroded  from  the  mucosa  of  the  kidney  pelvis,  from  the  bladder  and  urethra,  and 
from  the  skin  and  mucous  membrane  of  the  external  genitals.  Further,  when 
epithelial  cells  in  small  numbers  only  are  found,  absolutely  nothing  definite  can 
be  told  from  their  morphology  as  to  their  point  of  origin — a  fact  of  simple  ele- 
mental knowledge  of  normal  histology  which  is  too  often  forgotten  by  over- 
hopeful  and  inexperienced  microscopists.  When  large  flakes  of  epithelium  are 
thrown  off,  a  certain  amount  of  probability  may  be  given  to  statements  as  to 
the  point  of  origin,  but  nothing  of  sufficiently  definite  character  to  warrant  the 
adoption,  on  this  basis  alone,  of  operative  measures.  Occasionally  considerable 
bits  of  tissue  may  be  thrown  out  into  the  urine,  particularly  in  necrotic  forms  of 
inflammation  or  in  papillomatous  neoplasms. 

Too  much  reliance  must  not  be  placed  on  the  presence  or  absence  of  casts. 
Hyaline  casts,  even  in  considerable  numbers,  may  be  present  in  the  urine  from 
apparently  normal  kidneys,  particularly  after  diuresis,  and  even  granular  casts 
in  small  numbers  may  be  found  with  a  relatively  normal  excretion ;  conversely, 
extensive  and  even  fatal  nephritis  or  uremia  may  exist  without  the  presence  of 
casts.  Blood,  epithelial  and  pus  casts  are,  of  course,  indicative  of  disease ;  and, 
as  a  rule,  granular  casts  in  any  considerable  number  are  of  similar  import. 

Blood  in  the  urine,  if  certainly  derived  from  the  urinary  tract,  is  a  most  im- 
portant surgical  sign.  When  hajmoglobin,  with  perhaps  blood  serum  only,  is 
found,  as  in  the  heemoglobinuria  of  profound  malaria  or  in  toxemias  associated 
with  extensive  destruction  of  blood  corpuscles,  or  in  such  states  as  Raynaud's 


THE   BODY  FLUIDS   IN   SURGICAL   DISEASE.  571 

disease,  no  lesion  of  the  kidney  itself  is  indicated.  When  red  corpuscles  are 
found  in  the  urme,  it  is  permissible  to  assume  that  in  some  part  of  the  urinary- 
tract  there  exists  profound  congestion  or  even  inflammation,  or  that  there  is  a 
new-growth  or  a  granuloma.  The  quantity  of  the  blood  and  the  time  when  it 
appears  in  the  urine,  taken  with  the  other  clinical  symptoms  and  signs,  usually 
indicates  sufficiently  where  the  lesion  is  located. 

Pus  in  the  urine  is,  of  course,  confirmatory  of  inflammatory  disease  m  the 
urinary  tract.  When  it  is  continuously  well  mixed  with  the  urine,  suppuration 
of  the  renal  tissue  or  pelvis  is  indicated;  when  it  is  associated  with  blood  and 
crystals,  stone  is  to  be  considered;  or  when,  in  addition  to  the  pus,  there  are 
fragments  of  tissue  and  blood,  a  neoplasm  or  tuberculosis  is  suggested.  Wher- 
ever pus  is  found  in  the  urine,  specimens  secured  under  aseptic  conditions 
should  be  examined  bacteriologically.  Occasionally  mere  examination  of  prop- 
erly prepared  smears  is  sufficient,  as  in  gonorrheal  infection ;  but  often  bacterial 
cultures,  with  isolation  of  all  the  organisms  present,  are  necessary.  Where  tu- 
berculosis is  suspected  it  is  well  not  to  rely  exclusively  on  a  smear  examination 
in  any  case,  both  on  account  of  the  great  rarity  of  the  organisms  in  some  in- 
stances, and  on  account  of  the  difficulty  often  presented  in  the  distinction  of  the 
tubercle  bacillus  from  other  acid-fast  bacteria  frequently  present  in  the  urine. 
In  these  cases  animal  inoculation  is  the  only  safe  procedure. 

Crystalline  and  amorphous  deposits  in  the  urinary  sediment  are  of  great  sur- 
gical significance,  particularly  when  renal  or  cystic  calculus  is  suspected.  The 
most  important  of  these  deposits  are  uric  acid  or  urates,  calcium  oxalate,  and 
triple  phosphate.  Amorphous  phosphates,  when  out  of  solution  while  the  urine 
is  still  in  the  body,  are  also  frequently  involved  in  the  formation  of  stone,  partic- 
ularly when  associated  with  various  gums  and  colloidal  bodies  which  are  actively 
concerned  in  the  precipitation  of  urinary  salts  and  in  the  formation  of  stone. 
Rare  crystals  of  xanthin,  leucin,  or  tyrosin,  and  infecting  protozoa,  as  the 
trichomonas  or  Balantidium  coli,  are  infrequently  of  much  surgical  interest. 

The  F^ces. 

Examination  of  the  fseces  furnishes  a  most  direct  means  of  ascertaining  not 
'Only  the  condition  of  the  digestion  and  the  absorptive  powers  of  the  gastro- 
intestinal tract,  but  also,  in  many  cases,  the  state  of  outlying  viscera  and  the 
presence  or  absence  of  general  as  well  as  local  disease.  As  with  the  examination 
of  the  urine,  account  must  be  taken  of  the  food  and  drink  before  inferences  are 
drawn  from  the  appearance  or  from  an  analysis  of  the  stools.  Thus,  a  largely 
vegetable  diet  gives  rise  to  greater  and  softer  movements  than  one  mostly  of 
meat;  foods  rich  in  chlorophyl  give  a  green  color;  milk  gives  rise  to  abimdant 
light  yellow  movements;  while  drugs,  as  iron,  bismuth,  manganese,  as  well  as 
■certain  berries,  give  a  dark,  almost  black  color. 

Certain  inferences  are  to  be  drawn  from  the  shape  of  the  fseces.    Narrow, 


572  AMERICAN   PRACTICE   OF   SURGERY. 

ribbon-like  excreta  are  formed  in  rectal  stricture  or  in  nervous  spasm  of  the  anus; 
small,  roimd,  scybalous  masses  occur  in  constipation  or  sometimes  as  a  result  of 
a  highly  nitrogenous  diet. 

Gross  inspection  often  suffices  for  the  detection  of  such  bodies  as  the  larger 
parasites  (Fig.  144),  roimd  worms,  segments  of  taenia,  and  seeds  or  pits  of  fruit, 
bits  of  undigested  vegetable  matter,  gall  stones,  and  the  like.  Ordinarily  stea- 
torrhoea  can  also  be  diagnosed  by  gross  examination;  the  light  clay  color  of  the 
movement,  with  contained  fiakes  or  globules  of  white  fat,  indicating  deficient 
bile  flow,  disease  of  the  pancreas,  or  perhaps  a  diet  over-rich  in  fat. 

Blood  in  the  stools  may  be  readily  discovered  in  many  cases  by  the  unaided 
eye.    When  it  is  found  fresh  and  bright  red  in  color,  particularly  streaking  the 


Fig.  144. — Uncinaria  americana,  Male  and  Female.      From  a  case  of  severe  antemia  occurring  in 
a  soldier  returned  from  Porto  Rico. 

surface,  hemorrhage  from  the  anus  or  rectum,  as  from  hemorrhoids,  is  suggested. 
Large  amounts  of  fluid  or  clotted  blood,  but  slightly  altered,  indicate  hemor- 
rhage, perhaps  from  ulceration  in  the  lower  portion  of  the  small  intestine  or  from 
the  colon.  When  the  blood  is  well  mixed  with  the  stool  and  more  or  less  di- 
gested, the  color  of  the  movement  becomes  black  or  dark  green  and  carmot  be 
definitely  diagnosed  without  the  use  of  the  microscope  or  by  chemical  means. 
Such  findings  are  observed  in  intestinal  or  gastric  hemorrhage,  where  the  amount 
of  blood  lost  is  not  large,  and  they  may  signify  small  ulcers,  or  cancer  of  the 
stomach  or  small  intestine,  or  perhaps  simple  congestion,  as  might  take  place  in 
cardiac  incompensation  or  portal  thrombosis.  Intestinal  hemorrhage,  which, 
if  known,  would  be  of  the  greatest  diagnostic  value,  may  take  place  without 
produaing  in  the  stool  alterations  sufficient  to  attract  the  naked  eye  or  to  be 
discoverable  upon  microscopic  examination.  Thus,  in  the  early  stages  of  cancer 
of  the  stomachj  in  hook-worm  infection,  in  cirrhosis  of  the  liver,  and  in  many 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  573 

other  conditions  in  which  only  minute  quantities  of  blood  escape  into  the  bowel, 
chemical  examination  of  the  stool  may  be  necessary,  and  the  detection  of  blood 
by  the  guaiac  or  other  chemical  tests  becomes  in  such  instances  of  great  value. 
Mucus  in  excessive  amounts  ordinarily  indicates  catarrhal  colitis,  and,  when 
it  is  streaked  or  flecked  with  blood,  ulceration  is  to  be  considereel,  in  which  case 
bits  of  eroded  tissue,  globules  of  pus  cells,  and  small  masses  of  fibrin  are  ordinar- 
ily present.  When  considerable  masses  of  tissue  are  passed  the  surgeon  is  jus- 
tified in  suspecting  the  presence  of  a  new-growth,  and,  in  some  cases,  portions 
sufficiently  large  to  warrant  histological  examination  may  be  secured  and  may 
render  an  absolute  diagnosis  of  cancer  or  papilloma  possible.  It  must  not  be 
forgotten,  however,  that  animal  tissue  from  the  food  occasionally  passes  through 
the  entire  intestinal  tract  with  but  little  change,  and  it  is  therefore  wise  to  con- 


FiG.  145. — Amcebip  coli.  From  the  fa-ces  oi  a  case  of  tropical  abscess  of  the  Uver  occurring  in  a 
soldier  recenth^  returned  from  tlie  Philippine  Islands. 

sider  animal  tissues  as  always  derived  from  the  food  until  it  can  be  shown  that 
they  emanated  from  another  source.  Epithelial  cells  desquamated  from  new- 
growths  are  rarely  in  sufficient  number  to  excite  suspicion,  and  this  is  due  to  the 
simple  fact  that  the  cells  which  are  eroded  from  the  intestinal  mucosa,  under 
natural  circumstances  or  as  the  result  of  a  simple  inflammation,  are  very  nu- 
merous. 

In  all  the  departments  of  medical  science  study  of  the  faeces  for  the  detection 
of  animal  parasites  is  demanded,  and  in  no  branch  more  so  than  in  surgery.  The 
discovery  of  ova  of  the  anchylostoma,  for  example,  satisfactorily  explains  the 
type  of  often  actively  progressive  cachectic  anaemia  which  is  more  than  occa- 
sionally mistaken  for  that  of  a  malignant  tumor.  Demonstration  of  amoeba  coli 
(Fig.  145)  in  the  fecal  discharges  frequently  clears  the  diagnosis  of  abscess  of  the 
liver,  while  the  occurrence  of  ova  or  segments  from  the  various  ttenife  or  round- 


574  AMERICAN   PRACTICE   OF   SURGERY. 

worms  often  explains  otherwise  confusing  symptoms.  Bacterial  examination  of 
the  faeces  yields  in  some  cases  valuable  surgical  data.  The  mere  demon- 
stration of  typhoid  or  dysentery  bacilli,  now  no  longer  a  matter  of  great 
technical  difficulty,  renders  the  diagnosis  of  these  diseases  at  once  final  and 
conclusive. 

Perhaps,  however,  no  more  valuable  facts  are  ascertained  for  the  surgeon  by 
the  examination  of  the  faeces  than  are  given  him  by  careful  daily  study  in  con- 
valescent cases,  particularly  after  laparotomy — cases  in  which,  by  the  aid  of 
such  regular  examinations,  the  diet  may  be  regulated  according  to  the  digestive 
and  absorptive  peculiarities  of  each  individual  patient. 

THE  TRANSUDATES. 

The  importance  of  the  examination  of  the  transudates  lies  in  the  fact  that  we 
are  thereby  enabled  to  differentiate  them  from  the  exudates.  The  transudates 
are  of  passive  origin,  occurring  in  hydraemia,  in  circulatory  disorders,  and  in 
affections  in  which  the  liquids  are  insufficiently  excreted,  owing  to  defective 
action  on  the  part  of  the  kidneys,  skin,  or  bowel.  Any  of  these  conditions, 
therefore,  may  be  suggested  by  the  presence  of  transudates. 

The  character  of  transudates  differs  somewhat,  both  chemically  and  morpho- 
logically, according  to  their  location.  Thus,  those  from  the  pleural  cavities  are 
ordinarily  of  somewhat  higher  specific  gravity  than  those  occurring  elsewhere. 

Sedimentation  and  microscopic  examination  generally  disclose  a  few  epithe- 
lial cells,  macerated  and  desquamated  from  the  walls  of  the  involved  space,  or 
blood  cells,  usually  very  much  distorted  or  swollen. 

Absence  of  clot,  low  percentage  of  hjemoglobin,  and  lower  specific  gravity 
distinguish  the  transudates  from  the  exudates,  which  may  be  further  differen- 
tiated when  necessary  by  kryoscopy. 

THE  EXUDATES. 

Since  the  origin  and  nature  of  the  inflammatory  exudates  are  fully  discussed 
in  an  earlier  chapter,  we  shall  consider  them  here  briefly  and  only  in  their  im- 
mediate bearing  on  surgical  diagnosis. 

For  the  purposes  of  surgical  diagnosis  systematic  examination  must  be  prac- 
tised wherever  exudates  are  found.  An  examination  of  both  the  gross  and  the 
microscopic  appearances,  and  also  a  bacteriological  investigation,  are  of  much 
more  importance  than  chemical  methods,  although  these  must  also  be  occasion- 
ally employed. 

The  exudates  may  be  serous,  hemorrhagic,  chylous,  chyloid,  putrid,  or  puru- 
lent. Their  coagulability  and  general  character  can,  as  a  rule,  be  determined 
with  the  unaided  eye  at  the  operating  table,  but  the  microscope  is  usually  nec- 
essary to  furnish  the  more  important  data  as  to  probable  origin  or  precise  type. 


THE  BODY  FLUIDS  IN  SURGICAL  DISEASE.  575 

From  the  character  of  the  cells  contained  in  the  exudate  its  etiology  can  often 
be  accurately  determined. 

Serous  exudates  closely  resemble  transudates.  After  they  have  stood  for  a 
short  time,  however,  a  moderate  amount  of  clot  usually  separates  out  and  sedi- 
mentation shows  the  presence  of  formed  elements  having  more  or  less  marked 
characteristics.  Cells  dislodged  from  the  wall  of  the  cavity  into  which  exudation 
has  taken  place  are  usually  demonstrable,  and  leucocytes,  commonly  poly- 
nuclear  neutrophiles,  are  present  in  greater  or  less  number;  Where  the  exu- 
date has  been  of  long  standing  the  cells  usually  show  hydropic  degeneration, 
and  may  eventually  be  represented  only  by  amorphous  detritus. 

Hemorrhagic  exudates  are  characterized  by  the  presence  of  blood  in  consid- 
erable amount,  for  nearly  all  serous  exudates  and  even  the  transudates  contain 
a  few  red  blood  cells.  They  may  occur  after  traumatism,  in  pernicious  angemia, 
purpura,  haemophilia,  and  in  similar  hsemic  diseases,  but  are  most  commonly 
seen  associated  with  tuberculosis  or  malignant  neoplasms. 

Where  the  transudate  is  tuberculous  in  character,  it  is  usually  difficult  to 
demonstrate  the  tubercle  bacillus  except  by  animal  inoculation.  In  the  case  of 
cells  derived  from  a  new  growth,  it  will  often  be  found  that  they  exhibit  karyo- 
kinesis.  Furthermore,  such  cells  are  sometimes  present  in  such  numbers  as  to 
give  the  fluid  a  milky  turbidity.  When  small  pieces  of  the  new-growth  are  found 
in  the  fluid,  then  it  is  sometimes  possible  to  make  an  absolute  diagnosis  from  an 
examination  of  the  exudate  alone. 

Chylous  exudates  are  met  with  in  cases  in  which  lymjoh  channels  of  consid- 
erable size  have  broken  into  the  body  cavities.  They  are  rare,  but  are  readily 
recognized  by  the  presence  of  fat  and  oil  globules,  which  are  suspended  in  the 
fluid  in  such  a  manner  as  to  give  it  the  appearance  of  milk,  both  macroscopically 
and  microscopically. 

Chyloid  exudates  occur  when  extensive  destruction  of  epithelial  cells  takes 
place,  as  a  result  of  which  destruction  minute  fat  globules  and  much  cell  detritus 
are  set  free.  Such  exudates  are  mostly  found  in  cavities  the  walls  of  which  are 
either  cancerous  or  tuberculous. 

Putrid  exudates  are  recognized  by  their  foul  odor;  they  are  usually  dark  in 
color,  and  their  sediment  is  made  up  of  necrotic  detritus  only. 

The  purulent  exudates  contain  pus,  and  their  chief  characteristics  are  those 
of  pus.  In  certain  conditions  the  gross  appearance  alone  of  the  pus  suffices  to 
reveal  its  etiology  or  character.  Thus,  in  suppuration  caused  by  the  bacillus 
pyocyaneus  the  exudate  is  green  in  color,  and  infection  with  the  yellow  staphy- 
lococcus is  often  productive  of  a  pus  having  a  deep  golden  hue.  "\Anien  mixed 
with  blood,  the  fluid  acquires  a  characteristic  bloody  tinge;  when  it  emanates 
from  a  tuberculous  focus,  it  is  very  apt  to  contain  curds  and  coagula  of  whitish- 
gray  necrotic  material.  The  characteristics  of  pus  in  the  various  processes  are 
in  the  main  determined  by  the  etiological  factors  concerned  in  its  production. 


576  AMERICAN  PRACTICE  OF  SURGERY. 

For  this  reason  particular  attention  should  be  paid,  in  the  examination  of  pus, 
to  the  discovery  of  its  etiology.  In  many  cases  this  may  be  possible  from  the 
simple  examination  of  smear  preparations,  as  in  tuberculous,  gonorrhoeal,  and 
diphtheritic  exudates.  In  all  cases  special  staining  methods  should  be  em- 
ployed, viz.,  such  as  are  calculated  to  bring  out  the  factors  supposed  to  be  pres- 
ent in  each  case ;  or,  when  necessary,  several  methods  should  be  used,  as  are,  for 
example,  sometimes  required  for  the  absolute  identification  of  the  gonococcus. 

Where  many  bacteria  of  different  sorts  are  present,  it  is  usually  impossible, 
except  in  the  case  of  such  specific  inflammations  as  tuberculosis  or  gonorrhoea, 
to  decide,  from  this  brief  examination,  which  is  the  more  important.  In  these 
cases,  as  well  as  in  those  in  which  no  bacteria  or  protozoa  can  be  demonstrated 
in  smear  preparations,  cultures  on  appropriate  media,  and  often  tinder  both 
aerobic  and  anaerobic  conditions,  must  be  made,  and  the  various  organisms  iso- 
lated, and  their  respective  virulence  tested,  if  necessary,  by  animal  experiment. 
In  some  cases  direct  animal  inoculation  is  to  be  preferred,  particularly  when  the 
question  of  tuberculous  infection  arises  and  when  the  bacilli  are  not  sufficiently 
abundant  to  admit  of  easy  detection  by  the  ordinary  staining  methods. 

Certain  specimens  of  pus  are  best  examined  fresh,  as,  for  example,  the  pus  of 
liver  abscess,  for  the  reason  that  the  demonstration  of  the  amoeba  coli  is  more 
easily  accomplished  in  this  manner  than  when  it  has  been  stained;  but,  as  a 
rule,  stained  preparations  are  to  be  preferred. 

Pus  should  always  be  carefully  searched  for  cells  or  bits  of  tissue  that  may 
have  been  dislodged  from  the  primary  seat  of  the  disease,  which  may  be  thus 
disclosed.  This  is  often  of  value,  particularly  in  malignant  tumors,  where  active 
growth  is  closely  associated  with  necrosis. 

Certain  points  as  regards  the  age  of  pus  may  be  determined  by  submitting  it 
to  a  microscopic  examination.  Thus,  when  it  is  of  rather  recent  formation,  the 
leucocytes  and  other  cells  contained  in  the  fluid  are  as  a  rule  well  preserved,  and 
the  pus  cells  retain  to  a  large  extent  their  typical  neutrophilic  granule-staining 
reaction.  On  the  other  hand,  when  the  pus  is  old  these  bodies  are  largely  or 
entirely  broken  down,  the  serum  may  have  become  absorbed,  and  the  pus  may 
be  represented  only  by  a  sterile,  cheesy  material,  sometimes  more  or  less  calcified. 

CYST  CONTENTS. 

Diagnosis  as  to  the  origin  of  most  cysts  is  possible  from  the  examination  of 
their  contents.  In  many  cases  such  an  examination  is  of  the  utmost  importance 
to  the  diagnostician,  particularly  when  differentiation  between  true  cysts  and 
neoplasms  which  have  undergone  cystic  degeneration  is  necessary.  Encapsu- 
lated accumulations  of  inflammatory  exudates,  resembling  cysts,  may  also  be 
recognized  in  this  manner.  In  some  cases  microscopic  study  of  the  material 
aspirated  from  the  cavity  suffices  for  the  diagnosis,  as  in  the  ordinary  ovarian 
cysts,  but  in  a  certain  number  of  cases  chemical  investigation  is  also  necessary. 


THE   BODY   FLUIDS   IN   SURGICAL  DISEASE.  577 

C}'sts  of  the  kidney  or  simple  hydronephrosis  may  be  recognized  by  the  de- 
tection of  urea  or  uric  acid  in  the  cystic  fluid.  Hydatid  cysts  are  manifested  by 
the  presence  of  the  hydatid  hooklets  or  scolices  (Fig.  143),  cysts  of  the  hver  by 
tlie  presence  in  the  fluid  of  bile-coloring  matter,  and  pancreatic  cysts  may 
sometimes  be  identified  bj^  tryptic  reactions  obtainable  with  the  fluid  aspirated 
from  them. 

In  the  case  of  dermoids  and  the  more  solid  cysts,  as  of  the  thyroid  gland, 
diagnosis  is  commonly  possible  by  the  gross  or  microscopic  inspection  of  the  ma- 
terial removed,  although  aspiration  of  these  cysts  is  often  impossible,  especially 
where  hair  or  teeth-like  structures  are  present.  In  nearly  all  instances  removal 
of  a  portion  of  the  contents  through  small  incisions  and  the  use  of  the  micro- 
scope render  diagnosis  easy. 


THE  EPIPHYSES  AND  THEIR  RADIOGRAPHIC 
INTERPRETATION. 

By  PRESTON  M.  HICKEY,  M.D.,  Detroit,  Michigan. 


The  introduction  of  the  Roentgen  ray  as  a  diagnostic  aid  in  surgery  lias 
led  to  the  establishment  of  a  special  field  of  study  which  may  be  termed  radio- 
graphic anatomy.  The  intelligent  use  of  the  radiograph  presupposes  on  the  part 
of  the  observer  some  knowledge  of  the  radiographic  art,  as  well  as  some  ac- 
quaintance with  the  normal  and  pathologic  appearances.  The  successful  use  of 
the  microscope  as  an  aid  in  clinical  medicine  demands  a  preliminary  laboratory 
training  the  results  of  which  are  valuable  in  proportion  as  the  technique  is 
exact  and  the  observer  experienced.  To  realize  the  value  of  radiography  the 
proper  construction  must  be  placed  upon  the  findings  of  the  photographic  plate. 
The  lights  and  shadows  coaxed  forth  from  the  creamy  surface  of  the  sensitive 
film  by  the  chemical  developer  must  be  interpreted  in  the  light  of  a  previous 
training  in  this  special  field,  and  not  judged  through  preconceived  ideas  based 
on  inadequate  data. 

The  radiographic  study  of  the  human  bony  framework  during  its  process 
of  development  presents  varying  pictures  which  often  prove  deceptive  to  the 
inexperienced.  Before  taking  up  in  a  series  the  various  plates  which  are  ob- 
tained at  different  ages,  it  would  be  well  to  remember  that  all  radiographs  are 
produced  according  to  the  laws  of  projection  and  should  be  interpreted  with 
a  full  understanding  of  these  laws.  The  Roentgen  ra3^s  given  off  from  a  Crookes 
tube  properly  energized  proceed  principally  from  a  central  point  on  the  target 
of  the  tube.     These  rays  diverge  in  a  definite  ratio. 

Fig.  146  illustrates  this  point.  The  further  removed  the  oJDJects  are  from  the 
photographic  plate  and  the  nearer  they  are  to  the  target  from  which  the  rays 
emanate  the  greater  will  be  their  apparent  magnification.  Rays  which  come 
off  at  somewhat  of  a  tangent  to  the  target  will  produce  more  distortion  than 
the  more  direct  rays.  The  practical  lesson  to  be  drawn  from  these  observa- 
tions is  that  the  target  of  the  tube  should  be  placed  as  exactly  as  possible  over 
the  part  which  is  to  be  radiographed,  and  the  part  which  we  most  desire  to  be 
clearly  sho^vn  should  be  approximated  to  the  photographic  plate. 

Bodies  between  an  x-ray  tube  and  the  photographic  plate  cast  shadows 
upon  the  plate  proportionately  to  their  atomic  weights.  In  the  human  body, 
tissues  containing  lime  cut  off  the  ray  more  than  does  muscle  or  cartilage ;  hence. 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     579 

the  unossified  ends  of  the  bone  cast  such  feeble  shadows  that  they  are  practi- 
cally invisible  in  the  ordinary  radiograph. 

In  Fig.  147  is  presented  a  radiograph  of  a  new-born  child  delivered  at  seven 
months;  it  shows  at  a  glance  the  condition  of  the  long  bones  and  the  wide  spaces 
between  them  occupied  as  yet  by  only  soft  tissues.  The  striking  flexibility  of 
the  joints  and  their  natural  protection  against  fractures  at  this  early  age  are 
well  illustrated.  The  epiphyses  of  the  long  bones,  being  still  cartilaginous,  are 
photographically  invisible.  The  carpal  and  tarsal  bones,  with  the  exception 
of  the  OS  calcis,  are  absent. 

The  development  of  the  carpus,  from  a  radiographic  standpoint,  shows  that 
the  OS  magnum  and  the  unciform  are  first  noted  in  the  order  of  appearance  of 


Fig.  146, — The  Rays  from  the  Target  of  the  x-ray  Tube,  AK,  diverge  from  one  point  so  tliat  the 
object  O,  met  first  by  the  rays,  would  appear  larger  on  the  photographic  plate,  SP,  than  it  would 
on  a  similar  plate  (5'  P')  situated  fartlier  awa}'  from  the  tube. 

the  various  osseous  centres.  These  bones  usually  ossify  during  the  first  few 
months  of  life.  In  an  infant  at  the  age  of  fifteen  months  we  are  accustomed  to 
find  the  lower  epiphysis  of  the  radius  manifesting  itself  first  as  a  small  point. 
During  the  second  j-ear  of  life  these  two  bones,  the  os  magnum  and  the 
imciform,  and  the  lower  epiphysis  of  the  radius  increase  in  size,  Avhile  as  their 
growth  advances  we  find  that  the  proximal  epiphyses  of  the  first  row  of  the 
phalanges  begin  to  make  their  appearance. 

The  next  carpal  bone  that  can  be  distinguished  is  the  cuneiform.  Fig.  148, 
which  represents  the  hand  and  WTist  of  a  child  at  fi'^'e  }'ears  of  age,  shows  four 
of  the  carpal  bones  present,  namely,  the  os  magnum,  the  unciform,  the  cunei- 
form, and  the  semikmar.  Tlie  lower  epiphy>sis  of  the  radius  is  well  formed. 
Tlie  lower  epiphysis  of  the  ulna  has  not  yet  appeared.  The  epiphyses  of  the 
phalanged  bones  are  ail  more  or  less  distinctly  visible,  while  tlie  metacarpals 
show  their  distal  epiphyses. 


580 


AMERICAN   PRACTICE   OF   SURGERY. 


/n\ 


% 


Fig.  147. — Radiograph  of  a  Xen-born  Child  Delivered  at  Seven  Months.  The  epiphyses  of  the  meta- 
carpals and  phalangeal  bones  have  not  yet  appeared.  The  carpus  is  still  cartilaginous  and  lience  pro- 
duces no  shadows  on  the  photographic  plate.  The  humerus,  radius,  and  ulna  present  no  bony  ep- 
iphyses. The  lateral  centres  for  the  sacrum  are  distinct.  The  ilia  are  distinct  from  theos  pubis  to  the 
ischia,  which  are  united  at  their  superior  ends.  The  head  of  the  femur  produces  no  shadow,  while  in 
the  knee  joint  the  distance  between  the  femur  and  the  bones  of  the  leg  is  quite  striking.     (Original.) 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     581 

In  Fig.  149,  which  represents  the  hand  and  wrist  at  eight  years,  we  note  the 
lower  epiphysis  of  the  uhia.  The  scaphoid,  trapezium,  and  trapezoid  also  are 
distinct.  The  space  between  the  ossified  portions  of  these  carpal  bones  is  still 
considerable. 

The  lower  epiphysis  of  the  radius  appears  at  a  much  later  time  than  has 
been  assigned  by  the  older  anatomists,  usually  at  the  age  of  about  seven  year.s. 

In  the  wrist  at  eleven  years  (see  Fig.  150)  we  find  a  proximal  epiphysis — the 
epiphysis  of  a  second  metacarpal.  The  appearance  of  the  epiphyseal  line  might 
easily  be  mistaken  for  a  fracture  line.  The  second  metacarpal  is  peculiar  in  the 
fact  that  it  usually  develops  from  three  centres. 


Fig.  14S. — Radiograph  ot  Hand  at  Five  Years.  1,  Sliaft  of  fifth  phalangeal;  2,  epiphysis  of  same; 
3,  epiphysis  of  fifth  metacarpal;  4,  os  magnum;  5,  unciform;  6,  cuneiform;  7,  semilunar;  S,  ulna; 
9,  epiphysis  of  radius;  10,  radius.      (Original.) 

In  Fig.  151,  which  illustrates  the  wrist  at  twelve  years  of  age,  we  note  the 
peculiar  notch  at  the  proximal  end  of  the  second  metacarpal,  which  marks  the 
incomplete  union  of  this  bone  with  its  proximal  epiphysis: 

In  Fig.  152  we  note  the  superimposed  .shadow  of  the  pisiform  as_  covered  by 
the  greater  shadow  of  the  cimeiform. 

In  considering  the  development  of  the  carpus,  from  a  radiographic  stand- 
point, we  must  remember  that  there  are  considerable  variations  in  the  times 
at  which  the  different  wrist  bones  make  their  appearance.  While  the  above 
statements  will  be  true  of  the  great  majority  of  cases,  there  will,  howe^-er,  be 
some  to  which  these  statements  do  not  apply.  The  irregularity  may  be  present 
symmetrically  in  both  the  left  and  the  right  joints,  although  not  infrequently 


582 


AMERICAN   PRACTICE   OF   SURGERY. 


children  are  encoimtered  in  M-hom  the  osseous  development  of  one  carpus  is 
strikingly  different  from  that  of  its  fellow  on  the  opposite  side.  Local  condi- 
tions— such,  for  example,  as  a  pre-existing  tuberculosis — may  sometimes  be 
the  cause  of  this  irregularity.  None  of  these  peculiarities,  however,  will  give 
rise  to  an}^  considerable  difficulty  in  their  interpretation. 

Of  all  joints  in  the  body,  the  elbow  is  the  most  interesting  from  a  radio- 
graphic standpoint.     This  is  due  to  the  fact  that  there  are  so  manj-  different 


Fig.  149. — Hand  at  Eight  Years.  1.  Ungual  phalanx  of  thumb:  2,  epiphysis  of  same; 3,  proximal 
phalanx  of  thumb;  4,  epiphysis  of  same;  5,  first  metacaqDal;  6,  epiphysis  of  same;  7,  trapezoid:  S, 
trapezimn;  9,  os  magnum;  10,  scaphoid;  11,  lower  epiphysis  of  radius;  12,  radius;  13,  fifth  ungual 
phalanx;  14,  epiphysis  of  same;  15,  second  phalanx  of  little  finger;  16,  epiphj'sis  of  same;  17,  third 
phalanx  of  little  finger:  IS,  epiphysis  of  same;  19,  cpipliysis  of  fifth  metacarpal;  20.  fifth  metacarpal: 
21,  unciform;  22,  cuneiform;  23,  semilunar:  24,  lower  epiphysis  of  uhia;  25,  ulna.      (Original.) 

centres  of  development  in  the  elbow,  in  consec[uence  of  which  the  appearance 
of  the  elbow  joint  varies  radiographically  year  by  year  from  birth  to  the  age  of 
sixteen.  "\Mien  radiography  was  first  cmploj^ed  in  the  study  of  injuries  of  the 
elbow  joint,  many  mistakes  were  made  in  diagnosis,  through  lack  of  knowledge 
of  the  normal  appearance  of  the  joint  at  successive  ages.  Injuries  about  the 
elbow  in  children  naturally  present  difficulties  in  diagnosis  owing  to  the  com- 
plexity of  the  structures  involved.     The  bony  structures  contiguous  to  the 


RADIOGEAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     583 


Fig.  150. — WrhSt  at  Eleven  Years.  1,  Epiphy.«is  of  fifth  metacarpal;  2,  shaft  of  fifth  metacarpal; 
3,  miciform:  4,  os  magnum;  5,  cuneiform;  6,  semilunar;  7,  lower  epiphysis  of  ulna;  8,  ulna;  9,  sec- 
ond metacarpal:  10,  epiphj'sis  of  same;  11,  epiphysis  of  first  metacarpal;  12,  trapezoid;  13,  trape- 
zium; 14,  scaphoid;  15,  lower  epiphysis  of  radius;  16,  radius.      (Original.) 


Fig.  151. — Wrist  at  Twelve  Years.  1,  Proximal  phalanx  of  thumb;  2,  epiphysis  of  same;  3,  first 
metacarpal;  4,  notch  marking  nearly  completed  union  of  second  metacarpal  and  its  epiphysis;  5, 
epiphysis  of  first  metacarpal;  6,  trapezoid;  7,  trapezium;  S,  scaphoid;  9,  lower  epiphysis  of  radius; 
10,  radius;  11.  proximal  phalanx  of  little  finger;  12,  epiphysis  of  same;  13,  epiphysis  of  fifth  meta- 
carpal; 14,  fifth  metacarpal;  15,  os  magnum;  16,  unciform;  17,  cuneiform;  18,  semilunar;  19,  lower 
epiphysis  of  ulna ;  20,  ulna.     (Original.) 


584 


AMEEICAN  PRACTICE   OF  SURGERY, 


joint  develop  usually  from  nine  centres,  which,  however,  are  not  ahva3's  radio- 
graphicallj'  distinct.  Cases  have  been  recorded  in  which  a  fracture  was  supposed 
to  have  been  present  in  an  injured  elbow,  and  the  attending  ph}'sician  was 
misled  by  the  radiograph,  thinking  that  the  epiphyseal  lines  were  solutions  of 


Fig.  152. — Hand  at  Thirteen  Years.  1,  Epiphysis  of  fourth  metacarpal ;  2,  fourth  metacarpal:  3, 
unciform;  4,  os  magnum;  .5,  cuneiform;  6,  pisiform;  7,  lower  epiphysis  of  radius;  S,  lower  epiphysis 
of  uLna;  9,  ulna;  10,  radius;  11,  shaft  of  first  metacarpal;  12,  epiphysis  of  same;  13,  trapezium  with 
coalescing  shadow  of  trapezoid;  14,  scaphoid;  15,  semilunar.      (Original.) 


Fig.   153. — Radiograph  Showing  Lateral  ^'iew  of  Elbow  at  Six  Years. 
3,  upper  epiphysis  of  radius;  4,  radius;  5,  ulna.      (Original.) 


1,  Humerus;  2,  capitellu 


continuity  caused  by  violence.  In  the  interpretation  of  radiographs  of  the 
elbow,  greater  care  is  necessary  to  secure  proper  reading  of  the  appearances 
presented  than  in  any  other  part  of  the  body. 

The  first  manifestation  of  an  epiphyseal  nucleus  in  the  elbow  is  that  of  the 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     585 

capitellum,  which  appears  in  the  form  of  a  httle  rounded  knob  usually  during 
the  second  or  third  }'-ear  of  life. 

In  Fig.  153,  which  is  a  lateral  view  of  the  elbow  at  six  years  of  age,  the  capi- 
tellum has  attained  considerable  size,  so  that  it  projects  somewhat  into  the 


Fig.  154.— Radiograph  Showing  Lateral  View  of  Elbow  at  Seven  Years.      1 ,  Humerus ;  2,  capitellum ; 
upper  epiphysis  of  radius.      (Original.) 


3,  upper 

rounded  space  formed  by  the  greater  sigmoid  cavity.  In  this  figure  we  note 
the  appearance,  as  yet  barely  distinguishable,  of  the  upper  epiphysis  of  the 
radius,  which  shows  itself  first  as  a  little  button-like  body. 


Fig.  155.— Radiograph  Showing  Lateral  \'icw  of  Elbow  at  Ten  Years.    1,  Humerus;  2,  capitellum; 
3,  upper  epiphysis  of  radius;  4,  radius;  5,  epipliysis  of  olecranon;  6,  ulna.      (Original.) 

In  Fig.  154  the  capitellum  occupies  more  of  the  sigmoid  cavity  while  the  upper 
epiphysis  of  the  radius  is  much  more  distinctly  visible. 


586 


AMERICAN  PRACTICE  OF  SURGERY. 


In  Fig.  155  we  see  at  ten  years  of  age  the  primar}'  centre  for  the  olecranon. 
The  capitelhim  at  this  age  has,  superimposed  upon  it,  the  shadow  of  the  trochlea, 
which,  however,  in  lateral  views  of  the  joint,  cannot  usuall}'  be  made  out.  The 
upper  epiphysis  of  the  radius  has  increased  in  size  so  that  its  diameter  is  about 
eriual  to  the  diameter  of  the  shaft  of  the  radius. 


Fig.    156. — Radiograph  Showing  Lateral  View  of  Elbow  at  Eleven  Years.    (Variation.)   1,  Humerus; 
2,  capitellum;  3,  upper  epiphysis  of  radius;  4,  radius;  .5,  ulna.      (Original.) 


Fic.  157. — Lateral  View  of  Elbow  at  Fourteen  Years.  1,  Humerus;  2,  capitellum;  3,  upper  ep- 
iphysis of  radius;  4,  radius;  5,  secondary  centre  for  olecranon ;  6,  primarj' centre  for  olecranon  ;  7,  ulna. 
(Original.) 

Fig.  156  shows  the  elbow  joint  at  eleven  j^ears  of  age.  In  this  plate  no  trace 
of  the  olecranon  is  j^et  discernible.  This  must  be  considered  simply  as  an 
irregularity  of  dcA-elopment  in  a  particular  indi^'idual.  The  other  epiphyses 
show  the  degree  of  development  normal  for  that  age. 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     587 

In  Fig.  157,  which  is  a  lateral  view  of  the  elbow  at  fourteen,  we  find  that  the 
primar}^  centre  for  the  olecranon  has  greatly  increased  in  size  and  that  a  second- 
arj'  centre  has  appeared.  These  usually  coalesce  during  the  next  six  months, 
giving  rise  oftentimes  to  a  peculiar  elongated  body.  Here  also  the  shadow  of 
the  trochlea  is  superimposed  upon  the  shadow  of  the  capitellum.  The  shadow 
of  the  trochlea  is  posterior  to  the  shadow  of  the  capitellum,  while  the  shadow 
of  the  internal  condyle  cannot  usually  be  differentiated  in  a  lateral  view.  Their 
superimposed  lines  often  make  their  recognition  a  matter  of  some  difficulty. 

In  Fig.  158  we  have  a  lateral  view  of  the  elbow  at  age  fifteen,  which  shows  the 
partial  union  of  the  olecranon  to  its  shaft.  The  serrated  line  which  marks  the 
partial  epiphyseal  separation  has  been  oftentimes  mistaken  for  a  fracture  line. 
In  two  cases  of  injury  which  came  under  the  writer's  observation,  the  patients 
were  compelled  to  wear  splints  for  several  weeks  owing  to  the  misinterpreta- 


FiG.  158- — Radiograph  Showing  Lateral  Meu'  of  Elbow  at  Fifteen  Years.  I,  Plumerus;  2,  capitel- 
lum; 3,  upper  epiphysis  of  radius;  4,  radius;  5,  comi^act  tissue  of  the  lower  end  of  humerus;  6,  ep- 
il^hj'sis  of  olecranon  j^artial  joint;  7,  ulna.      (Original.) 


tioninthisrespectof  the  radiogram  of  the  injured  joint.  At  age  sixteen  the  separa- 
tion between  the  epiphysis  belonging  to  the  radius  and  its  diaphysis  is  so  slight 
as  often  to  escape  notice. 

The  vertical  view  of  the  developing  elbow  is  perhaps  more  deceptive  than 
the  lateral  views  and  requires  study  for  its  comprehension.  In  Fig.  159  is  seen 
the  elbow  joint  of  a  six-year-old  boy.  The  capitellum  is  well  formed  while 
the  small  disc  of  the  epiphysis  of  the  radius  is  sharply  shown. 

In  Fig.  160,  which  is  a  vertical  view  of  the  elbow  at  age  ten,  the  centre  for  the 


5SS 


.\.MERICAX   PRACTICE   OF   SURGERY. 


iuternal  condyle  is  well  formed.  The  capitellum  is  -n-ell  sho-nii;  the  superim- 
position  of  the  trochlea  over  the  shadow  of  the  sigmoid  cavity  pre^'ents  its 
recognition. 

In  Fig.  161.  which  is  a  vertical  view  of  the  elbow  at  age  eleven,  we  find  the 
upper  epiphj'sis  of  the  radius  remarkaljly  well  defined.     The  capitellum  shows  a 


Fig.  159. — Xeitical  View  of  Elbow  at  Six  Years.      1,  Humerus;    2,  ulna;   3,  capitellum;  4,  upper 
epiphysis  of  radius;  5,  radius.      (Original.') 


Fig.  160. — Vertical  View  of  Elbow  at  Ten  Years.      1,  Humerus;  2,  trochlea;  3,  capitellum;  4,  ep- 
iphysis of  radius;  5,  radius      (Original.) 

partial  attachment  to  the  shaft,  although  the  internal  edge  is  distinctlj'  sepa- 
rated. The  olecranon  fossa  manifests  itself  as  a  rounded  space  of  less  density 
than  the  adjacent  thicker  an(_l  more  compact  bone  tissue.  At  this  age  the  centre 
for  the  internal  condjde  is  also  quite  distinct  from  the  diaphysis. 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     589 

In  Fif.  162 — a  vertical  view  of  tlie  elbow  at  age  twelve — the  internal  condyle 
is  partly  attached  to  its  shaft.  Oftentimes  in  carefully  prepared  plates  the  epi- 
physis of  the  olecranon  can  be  made  out  in  the  light  shading  of  the  olecranon 
fossa.     On  the  external  surface  the  capitellum  has  increased  in  size,  and  the 


Fig.  161. — Radiograph  PUowing  Vertical  View  of  Elbow  at  Eleven  Years.     1,  Hi. 
fossa;  3,  capitellum;  4,  upper  epiphy.si.s  of  radius;  5,  radius;  6,  trochlea;  7,  ulna.      (Original.) 


Fig.  162. — Radiograph  Showing  Vertical  View  of  Elbow  at  Twelve  Years.      1,  Capitellum;  2,  upper 
epiphysis  of  radius;  3,  radius;  4,  humerus;  5,  trochlea;  6,  ulna.      (Original.) 

trochlea  can  often  be  made  out  with  its  shadow  superimposed  on  that  of  the 
sigmoid  cavity.     The  upper  epiphysis  of  the  radius  is  still  ununited. 


590 


AMERICAN   PRACTICE   OF   SURGERY. 


In  Fig.  163,  which  is  a  vertical  view  of  tlie  elbow  at  age  thirteen,  we  find  the 
centre  for  the  olecranon  manifesting  itself  more  distinctly  through  the  shadow 
of  the  olecranon  fossa.     The  peculiar  appearance  of  the  capitellum  should  be 


Fig.   16: 
3,  liurnerus 


. — Radiograph  Showing  '\'ertical  Mew  of  Elbow  at  Tliirteen  Years.      1,  Trochlea;  2,  ulna; 
4,  capitellum;  5,  upper  epiphysis  of  radius;  6,  radius.      (Original.) 


Fig.  164. — Shoulder  Joint  at  Eleven  Years.     1,  Coracoid  process;  2,  distal  extremit.v  of  cla-vicle ; 
3,  acromion  process;  4,  head  of  humerus;  5,  epiphj-seal  line;  6,  shaft  of  humerus.     (Original.) 

noticed,  since  on  its  upper  and  outer  border  we  find  an  irregular  projection 
which  marks  the  extension  of  the  bonj^  structure  m  its  endeavor  to  bridge  across 
the  intervening  space.     On  the  internal  side  the  internal  condyle  is  partly 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     591 


Fig.  165. — Radiograph  Sliowing  Hip  Joint  at  Seven  Years.      1,  Ischium  ;  2,  head  of  femur;  3,  centre 
of  greater  trochanter;  4,  femur.       (Original.) 


Fig.  166. — Hip  Joint  at  Eleven  Years.      1,  Ilium;  2,  liead  of  femur;  3,  great  trochanter.      (Original.) 


592 


AMERICAN   PRACTICE   OF   SURGERY. 


attached  to  its  shaft.  At  this  age  the  trochlea  can  usually  be  made  out  quite 
distinctly. 

The  radiographic  appearance  of  the  shoulder  joint  during  the  development 
of  the  child  does  not  usually  vary,  and  presents  no  particular  difficulties  of 
interpretation.  In  Fig.  164,  which  was  made  from  an  eleven-year-old  boy,  the 
epiphyseal  line  separating  the  head  of  the  humerus  from  the  shaft  is  distinctly 
seen.     This  ordinarily  persists  until  about  the  nineteenth  or  twentieth  year. 

In  Fig.  165,  which  represents  the  hip  joint  of  a  child  of  seven,  we  find  the  head 
of  the  femur  quite  distinct.  In  the  interpretation  of  radiographs  of  congenital 
dislocation  of  the  hip  it  is  important  to  remember  that  the  first  bony  appearance 
of  the  head  of  the  femur  ordinarily  occurs  at  the  end  of  the  first  year  of  life.  In 
the  same  figure  we  see  the  separate  centre  for  the  great  trochanter,  which  makes 


Fig.  167. — Radiograph  Showing  Lateral  View  of  Knee  Joint  at  Seven  Years.  1,  Patella;  2, 
upper  epiphysis  of  tibia;  3,  tibia;  4,  femur;  5,  lower  epiphysis  of  femur;  6,  upper  epiphysis  of  fibula. 
(Original.) 

its  appearance  at  widely  varying  periods,  sometimes  as  early  as  the  fourth 
year,  and  again,  in  some  cases,  not  until  the  eighth  year.  The  lesser  trochanter 
generally  makes  its  first  appearance  at  a  much  later  date,  usually  about  the 
eleventh  or  twelfth  year. 

In  Fig.  166  the  greater  trochanter  (at  age  eleven)  is  most  distinctly  shown.  It 
usually  unites  with  the  shaft  at  about  the  same  time  as  when  the  epiphyseal 
line  between  the  head  of  the  femur  and  the  shaft  disappears;  namely,  about 
the  eighteenth  year. 

The  lower  epiphysis  of  the  femur  is  shown  in  Fig.  167,  which  is  a  lateral  view 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     593 

of  the  knee  joint  at  seven  years  of  age.  The  patella  is  a  bone  which  radiograph- 
ically  appears  at  different  ages — usually  after  the  third  or  fourth  year;  it  pre- 
sents the  form  of  a  rounded  shadow  without  the  well-defined  angles  which  later 
distinguish  it. 

The  upper  epiphysis  of  the  tibia,  as  well  as  the  upper  epiphysis  of  the  fibula, 
usually  appears  during  the  second  year  of  life.  The  development  of  these  epiph- 
yses and  the  change  in  shape  of  the  patella  are  illustrated  in  Fig.  168,  which  is 
a  lateral  view  of  the  knee  at  age  eleven.  During  the  next  year  the  upper  epiphysis 
of  the  tibia  throws  out,  from  its  lower  part,  a  projection  which  is  fashioned 


Fig.  16S. — Lateral  View  of  Knee  Joint  at  Eleven  Years.  1,  Patella;  2,  inner  condyle;  3,  epiphys- 
eal line  at  upper  end  of  tibia;  4,  epiphyseal  line  between  the  femur  and  the  outer  condyle;  S,  outer 
condyle;  6,  spine  of  tibia;  7,  upper  epiphysis  of  fibula.      (Original.) 


somewhat  like  a  tongue — a  projection  which  afterward  becomes  the  tubercle 
of  the  tibia. 

The  antero-posterior  view  of  the  knee  joint  is  shown  in  Fig.  169,  which  was 
made  with  the  posterior  surface  of  the  joint  next  to  the  photographic  plate. 
The  distance  of  the  patella  from  the  plate  increases  its  apparent  size,  so  that 
its  shadow  is  less  distinct  and  can  scarcely  be  differentiated  from  the  lower  end 
of  the  tibia.  The  spinous  process  of  the  tibia  is  shown  as  it  projects  into  the 
joint  space.  The  epiphyseal  lines  are  so  distinct  and  regular  that  their  appear- 
ance is  not  likely  to  lead  to  a  misinterpretation. 
VOL.  I.— 38 


594 


AMERICAN  PRACTICE  OF  SURGERY. 


Fig.  169. — Radiograph  Showing  Vertical  View  of  Knee  at  Eleven  Years.  1,  Femur;  2,  patella;  3, 
lower  epiphysis  of  femur;  4,  spine  of  tibia;  5,  upper  epiphysis  of  tibia;  6,  tibia;  7,  upper  epiphysis  of 
fibula;  S.  fibula.      (Original.) 


Fig.  170. — Vertical  View  of  Ankle  Joint  at  Eleven  Years.    1,  Tibia;  2,  fibula;  3,  epiphyseal  line  of 
fibula;  4,  lower  epiphj-sis  of  fibula;  5,  epiphyseal  line  of  tibia;  6,  lower  epiphysis  of  tibia.     (Original.) 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     595 


Fig.  171. — Radiograph  Showing  Lateral  View  of  Ankle  at  Seven  Years.  1,  Superimposed  shadow 
of  fibula;  2,  lower  epiphysis  of  tibia;  3,  astragalus;  4,  os  calcis;  5,  tibia;  6,  scaphoid;  7,  cuboid. 
(Original.) 


Fig.  172. — Lateral  View  of  Ankle  at  Eleven  Years.  1,  Tibia;  2,  lower  epiphysis  of  tibia;  3,  astrag 
alus;  4,  scaphoid;  5,  os  calcis;  6,  epiphysis  of  os  calcis;  7,  cuboid.     (Original.) 


596 


AMERICAN   PRACTICE   OF   SURGERY. 


Fig.  170  is  a  vertical  view  of  the  ankle  at  age  eleven;  the  lower  epiphysis  of 
the  fibula,  as  it  forms  the  external  malleolus,  is  a  well-known  object.  On  the  in- 
ternal side  the  broad  epiphysis  of  the  tibia  is  shown  above  the  talo-crural  joint. 

In  Fig.  171,  which  is  a  lateral  view  of  the  ankle  joint  at  seven  years  of  age, 
the  distance  between  the  tarsal  bones  is  strikingly  obvious.  At  birth  the  tarsus 
usually  shows  a  small  centre  for  the  os  calcis  and  one  for  the  astragalus.  The 
cuboid  appears  during  the  fifth  month,  while  the  scaplioid  is  first  seen  about 
the  fourth  year.     The  considerable  space  which  is  present  between  the  bony 


Fig.  173. — Radiograph  Showing  Lateral  View  of  Ankle  at  Tweh-e  Years.  1,  Scaphoid;  2,  internal 
cuneiform;  3,  cuboid;  4,  tibia;  5,  lower  epiphysis  of  tibia;  6,  fibula;  7,  astragalus;  S,  os  calcis;  9,  ep- 
iphysis of  os  calcis,      (Original.) 

centres  of  the  tarsal  bones  before  the  age  of  five  explains  at  a  glance  why 
moulding  operations  upon  the  foot  at  this  age  are  possible. 

The  epiphysis  of  the  os  calcis  appears  ordinarily  at  the  eighth  or  ninth  year. 
In  Fig.  172,  which  is  a  lateral  view  of  the  ankle  at  age  eleven,  this  epiphysis  is 
shown  in  an  already  ■\^'ell-advanced  state  of  development,  with  fine  osseous 
deposits  between  its  main  bodj^  and  the  os  calcis. 

Further  development  of  this  epij^hysis  occurs  during  the  following  year,  as 
is  shown  in  Fig.  173. 

In  Fig.  174,  which  gives  a  lateral  view  of  the  anlde  at  age  thirteen,  we  have  the 
partial  union  of  the  epiphysis  with  the  os  calcis.     This  union  may  take  place  a 


RADIOGRAPHIC  INTERPRETATION  OF  THE  EPIPHYSES.     597 


Fig.  174. — Radiograph  Showing  Lateral  View  of  Ankle  at  Thirteen  Years.  1,  Tibia;  2,  fibula;  3, 
lower  epiphysis  of  tibia;  4,  astragalus;  5,  scaphoid;  6,  internal  cuneiform;  7,  cuboid;  S,  lower  ep- 
iphysis of  fibula;  9,  os  cal-cis;  10,  epiphj^sis  of  os  calcis.     (Original.) 


Fig.  175.— Radiograph  Showing  Lateral  View  of  a  Cretin's  Foot  at  Twelve  Ye 
cuboid;  3,  tibia;  4,  fibula;  5,  astragalus;  6,  cs  calcis.     (Original.) 


1.  Scaphoid: 


598  AMERICAN  PRACTICE  OF  SURGERY. 

year  or  so  later.  In  this  radiogram  tlie  distance  between  the  tarsal  bones 
approaches  that  of  the  adult  foot. 

The  general  development  of  the  child  may  oftentimes  be  inferred  with  a 
fair  degree  of  accuracy  from  the  degree  of  development  of  the  osseous  frame- 
work. In  Fig.  175,  which  is  a  lateral  view  of  the  ankle  of  a  cretin — twelve 
years  of  age, — we  find  the  bones  showing  the  degree  of  development  which  we 
should  ordinarily  find  at  four  years.  The  mental  development  of  the  patient 
corresponded  to  the  intelligence  which  we  should  expect  to  find  in  a  child  of 
five  years. 

In  interpreting  radiographs  of  injured  joints  of  children,  as  the  writer  has 
insisted  above,  some  experience  is  necessary.  We  should  be  familiar  with 
the  appearances  ordinarily  presented  at  different  ages,  and  we  should  be  able 
promptly  and  correctly  to  interpret  the  exceptions  which  may  occur.  Ordi- 
narily, it  is  a  safe  rule,  in  cases  of  obscure  injury,  particularly  about  the  elbow 
joint,  to  make  a  second  radiograph,  at  the  same  time,  of  the  uninjured  joint, 
for  the  purpose  of  comparing  it  with  the  radiograph  of  the  injured  joint, 
both  of  the  pictures  to  be  taken  under  the  same  conditions. 

It  has  been  the  experience  of  radiographers  that  epiphyseal  separations  are 
rarely  met  with.  The  clinical  diagnosis  of  a  traumatic  separation  of  the 
epiphysis  will  often  be  found  to  be  inaccurate,  as  the  radiograph  usually 
shows  a  solution  of  continuity  through  the  bony  structures  adjacent  to  the 
epiphyseal  line.  The  sudden  violence  at  the  time  of  injury  seems  to  snap  the 
bone  in  preference  to  pulling  apart  the  more  yielding  soft  tissues.  This  is 
perhaps  fortunate,  as  the  readjustment  of  the  bony  fragment  can  be  better 
effected  than  the  replacement  of  the  unossified  structures  nearer  the  joint. 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK  AS 
APPLIED  TO  SURGERY,  AND  THE  INTER- 
PRETATION OF  RADIOGRAPHS. 

By  Mr.  WALTER  J.  DODD  and  ROBERT    B.  OSGOOD,  M.D.,  Boston,  Mass. 


I.     RADIOGRAPHIC    TECHNIQUE 

The  development  of  x-ray  work  since  Roentgen's  discovery  has  been  rapid 
and  the  broadening  of  its  field  of  usefulness  has  been  great.  A  short  decade 
has  seen  the  interesting  plaything  of  surgery  absorb  the  attention  of  earnest  sci- 
entific workers  until  many  men  have  sacrificed  the  general  practice  of  medicine 
to  become  specialists  in  radiology,  or  even  to  devote  themselves  exclusively  to 
certain  branches  of  the  art. 

It  is  not  the  purpose  of  this  article  to  consider  in  great  detail  the  technique 
and  apparatus  necessary  for  these  special  x-ray  investigations,  but  rather  to 
outline  with  sufficient  clearness  apparatus  and  methods  which,  if  obtained  and 
followed,  will  allow  a  busy  practitioner  to  install  and  operate  an  x-ray  plant 
with  satisfaction  and  accuracy. 

In  large  centres  it  is  now  possible  to  obtain  x-ray  work  which  is  up  to  the 
best  modern  standards.  Its  field  of  usefulness,  however,  is  by  no  means  confined 
to  these  large  centres,  and  in  many  instances  the  advantages  of  office  plants  and 
personal  operation  far  outweigh  the  value  of  these  larger  x-ray  laboratories. 

We  wish  it  distinctly  understood  that  the  apparatus  here  suggested  and  the 
methods  advised  are  simply  those  which,  from  practical  experience,  we  know 
to  be  accurate  and  with  which  Avork  of  high  quality  can  be  done.  Where  sev- 
eral forms  of  apparatus,  of  nearly  equal  value,  have  been  devised,  the  simplest 
have  invariably  been  chosen  for  description.  The  methods  advised  should  be 
considered  for  the  most  part  as  working  bases  from  which  the  practitioner  begin- 
ning x-ray  work  may  start,  later  elaborating  and  adapting  them  to  his  indi- 
vidual needs. 

To  the  interpretation  of  x-ray  plates  far  less  space  has  been  given  than 
the  importance  of  the  subject  justifies.  The  writers  believe  that  here  again  the 
aim  of  the  work  should  be  to  suggest  broad  diagnostic  points,  feeling  sure  that 
the  power  of  finer  discrimination  can  come  satisfactorily  only  through  large  expe- 
rience and  patient  comparison  with  the  normal. 

In  the  description  of  the  characteristics  of  the  various  conditions  which  will 

.599 


600  AMERICAN   PRACTICE   OF   SURGERY. 

be  considered  later,  we  presuppose  good  and  even  lighting  of  the  plates,  such  as 
is  shown  in  Fig.  176.     This  illuminator  will  be  subsequently  described. 

We  wish  to  acknowledge  our  indebtedness  to  a  valuable  and  exlraustive  un- 
published paper  by  Dr.  E.  A.  Codman,  of  Boston,  and  to  the  work  of  Schuchardt, 
"Die  Krankheiten  der  Knochen  und  Gelenke"  ("  Deut.  Chir.,"  Bd.  xxviii.). 

We  shall  consider  the  evidence  of  the  various  diseases  in  the  skiagraph  alone 
without  discussing  the  histologic  and  pathologic  changes  or  the  detailed  etio- 
logic  factors. 

The  therapeutic  uses  of  the  2:-ray  have  been  exhaustive!}^  treated  in  avail- 
able books.  We  do  not  feel  qualified  to  speak  authoritatively  on  the  technique 
of  these  measures,  nor  of  their  value.  Pure  surgery  concerns  itself  little  with 
most  of  the  diseases  commonly  so  treated.  While  recognizing  differences  of 
opinion  among  careful  observers,  we  personally  feel  that  a;-ray  therapy,  except 


Fig.  176. — Illuminator.     Light,  evenlj'  diffused,  reflected  from  white  back  of  box. 

in  the  superficial  forms  of  epithelioma,  should  ne^'er  take  the  place  of  surgery 
in  operable  cases  of  cancer.  Although  differences  of  opinion  also  exist  as  to  the 
value  of  x-ray  treatment  following  operations  for  carcinoma,  the  evidence  in 
our  minds  seems  to  warrant  its  use  as  a  post-operative  safeguard  against  recur- 
rence. In  the  keratoses  and  superficial  epitheliomata  the  results  of  x-ray 
treatment  are  certainly  comparable  with  the  surgical  procedures.  In  the  treat- 
ment of  lupus  and  the  superficial  forms  of  tuberculosis,  it  undoubtedly  offers 
us  the  best  method  at  our  disposal  and  sho-s^-s  results  little  short  of  marvellous 
in  the  light  of  our  old  conceptions. 

Measurers  of  the  intensity  and  the  quality  of  the  rays  are  to  be  obtained  in 
varied  forms  of  greater  or  less  accuracy.  Some  of  these  meters  should  be  used 
in  therapeutic  work,  and  the  treatment  standardized  as  much  as  possible. 

A  knowledge  of  electricity  can  never  be  other  than  a  help  in  radiology.  We 
do  not  deem,  however,  an  intimate  acquaintance  with  the  subject  essential  to 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  601 

practical  x-ray  work.  The  basic  principles  must  be  known;  to  be  an  electrical 
engineer  is  unnecessary.  It  will  be  taken  for  granted  that  the  principles  of  con- 
duction and  induction  are  in  a  general  way  understood,  and  the  component  parts 
of  plants  adapted  to  different  forms  of  current,  or  to  an  entire  absence  of  avail- 
able current,  will  be  described.  The  following  list  comprises  what  we  consider 
the  essentials  of  an  x-ray  plant: 

Coil; 

Interrupter ; 

Several  good  x-ray  tubes; 

Rheostat ; 

Switchboard  with  ammeter  for  primary  circuit,  fuse  of  lower  reading  than 
main  fuse,  and  knife  switches; 

Compression  cylinder ; 

Adjustable  table  or  support  for  patients; 

Illuminating  lantern ; 

Solid  and  well-constructed  tube  holder. 


Coil. 

The  plant  about  to  be  described  has  been  submitted  to  the  severe  test  of 
hospital  as  well  as  large  office  practice.  No  originality  of  method  or  apparatus 
is  claimed,  the  purpose  of  the  writers  being  to  describe  apparatus  and  technicjue 
that  have  proved  to  be  practical,  simple,  and  satisfactory. 

In  order  to  do  quick  radiographic  work  the  coil  should  give  a  discharge  of 
at  least  4  to  8  inches.     It  is  not  simply  length  of  spark  that  is  needed,  but 


Fig.  177. — Illustrates  spark  spoken  of  as  thin  spark.  Impossible  to  get  higher  reading  than  3  mil- 
liamperes  witli  this  coil;  from  IJ  to  2  milliamperes  being  the  average  reading  with  16  amperes  on  pri- 
mary circuit.  Length  of  spark  8  inches.  Exposure  for  hip,  in  the  case  of  an  adult  weighing  160  lbs., 
from  2  to  3  minutes.      (Original.) 

volume.  A  coil  that  will  give  a  long,  thin  12-inch  spark  is  not  to  be  com- 
pared with  one  that  will  give  a  flaming  8-inch  spark.  The  flaming  discharge 
indicates  quantity,  and  quantity  is  essential  to  speed,  and  speed  is  essential  to 
good  work.  By  speed  we  do  not  mean  snap-shots.  We  must  keep  in  mind  the 
fact  that  we  are  not  dealing  with  light  from  one  source,  but  that  the  x-ray  light 
gives  rise  to  other  radiations,  all  of  which  have  more  or  less  influence  on  a  pho- 


602 


AMERICAN   PRACTICE   OF   SURGERY. 


tograpliic  plate.  For  this  reason  we  must  striA-e  to  get,  in  as  short  a  time  as  is 
consistent  with  good  work,  the  greatest  quantity  of  .r-ray  light,  thereby  eliminat- 
ing secondary  radiations  as  much  as  possible  The  coils  used  by  the  writers  are 
capable  of  giving  a  6-  to  10-inch  flaming  discharge  (Figs.  177  and  178)  when  used 
with  a  Wehnelt  interrupter;  the  ammeter  in  the  primary  reading  10  amperes, 
and  service  being  derived  from  a  direct  current  of  either  220  or  110  volts.  The 
primaries  of  these  coils  are  so  wound  that  self-induction  has  been  greatly  increased 
over  that  of  the  primaries  used  when  the  electrolytic  interrupter  was  first  intro- 
duced.    It  is  to   Dr.  Walters,  of  Hamburg,  that  the  credit  of  variable  primary 


Fig.  178. — Illustrates  flaming  discharge,  8  inches  in  length.  Meter  will  read  10  milliamperes  with 
10  amperes  on  primary  circuit.  Exposure  for  hip,  in  an  adult  weigliing  160  lbs.,  20  to  40  seconds. 
(Original.) 

inductance  should  be  given.     Such  winding  is  absolutelj'  essential  to  good  results 
with  the  Wehnelt  interrupter. 

All  large  coils  of  first-class  make  are  now  equijjped  with  primaries  of  this 
type  and  are  most  highly  recommended.  Coils  of  first-class  manufacture  will 
always  give  the  spark  at  M'hich  they  are  rated,  but  the  operator  is  advised  not 
to  submit  the  coil  to  such  strain.  Never  spark  the  coil  to  its  full  capacity.  You 
can  test  a  12-inch  coil  without  forcing  the  discharge  through  the  air  gap  of  12 
inches.  To  test  a  coil  of  12-inch  rating  the  writers  place  the  discharge  rods 
about  8  inches  apart  and  slowly  turn  on  the  current.  If  the  coil  is  in  good  work- 
ing order,  sparking  will  begin  with  a  thin,  continuous,  snappy  spark  which  is 
thicker  and  broader  at  one  end.  This  is  the  cathode  or  negative  terminal  of 
the  coil  and  should  be  marked  with  the  negative  sign.  As  more  current  is 
allowed  to  flow  in,  the  discharge  increases  until  finally  we  get  the  yellow  con- 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  603 

tinuous  spark.  Never  test  the  coil  by  sparking  unless  it  is  absolutely  nec- 
essary, as  the  coil  is  likely  to  become  overheated  and  affect  the  insulation  of 
the  secondary  circuit. 

Interrupter. 

The  purpose  of  the  interrupter  is  to  break  the  primary  current  rapidly  and 
completely,  while  at  the  same  time  the  period  of  make  is  long  enough  to  saturate 
the  primary  coil.  Mechanical  interrupters  of  modern  pattern  have  reached 
a  high  stage  of  perfection  and  are  heartily  endorsed  by  many,  but  the  current- 
carrying  capacity  of  all  mechanical  interrupters  is  low  and  the  time  of  expos- 
ure must  be  long  when  compared  with  an  mterrupter  of  high-current-carrying 
capacity,  such  as  the  liquid  electrolytic,  mercury,  and  Wehnelt.  As  the  writers 
believe  from  their  own  experience  that  the  Wehnelt  is  by  all  means  the  most 
satisfactory  for  good  radiographic  work  that  type  alone  will  be  described. 

The  action  of  the  electrolytic  interrupter  is  brought  about  by  electrolysis 
of  acidulated  water,  gas  forming  at  the  anode  or  positive  plate,  which  gas 
for  an  instant  envelops  that  plate  and  momentarily  breaks  the  current;  a  very 
high  rate  of  interruption  may  thus  be  obtained.  The  electrolytic  or  Wehnelt 
interrupter  consists  of  a  lead  plate  or  tube,  which  must  always  be  connected 
to  the  negative  termuial  of  the  main  current,  and  a  platinimi  point  which  must 
ahvays  be  made  positive.  These  are  then  placed  in  a  vessel  of  glass  or  earthen- 
ware containing  sulphuric  acid,  specific  gravity  1.20;  the  platinum  point  is 
usually  passed  through  a  glass  or  porcelain  tube,  the  strength  of  current  being 
dependent  upon  the  amount  of  platinum  surface  projecting  through  the  tube 
into  the  liciuid.  As  the  amount  of  current  depends  on  the  amount  of  platinimi 
surface  thus  exposed,  we  can  readily  see  that  we  have  at  hand  an  interrupter 
the  current-carrying  capacity  of  which  is  almost  imlimited  and  far  beyond 
what  it  is  possible  to  use  with  our  present  knowledge  of  tubes  and  coils.  The 
Wehnelt  interrupter  was  made  practicable  for  radiographic  work  by  Dr.  Walters' 
improvement  m  induction-coil  construction  whereby  the  self-induction  of  the 
primary  could  be  raised  by  using  two  or  more  layers  of  wire  according  to  the 
vacuum  and  spark  resistance  of  the  tube.  It  is  now  possible  to  use  the  Weh- 
nelt interrupter  when  employing  tubes  for  therapeutic  purposes.  By  raising  the 
self-induction  we  are  enabled  to  use  tubes  of  much  lower  vacuum;  and  the 
writers  have  used  such  tubes  for  over  twenty  minutes'  continuous  operation 
with  three  amperes  on  the  primary  circuit,  the  spark  length  of  the  coil  being 
a  heavy  10-inch  flaming  discharge  when  used  with  one  layer  of  primary,  where- 
as with  two  layers  of  primary  on  this  particular  coil  it  is  impossible  to  get  a  flam- 
ing discharge  of  more  than  three  and  one-half  inches  in  length  even  with  fif- 
teen amperes  on  the  primary  circuit.  It  is  interesting  to  note  that  the 
character  of  the  spark  is  almost  completely  changed  when  the  self-induction  is 
raised.    It  is  much  shorter,  but  at  the  same  time  much  thicker  (Fig.  177).     This 


604 


AMERICAN   PRACTICE   OF   SURGERY. 


fact  may  be  taken  advantage  of  to  operate  tubes  of  very  low  resistance,  and 
at  the  same  time  get  good  radiograpliic  results,  although  the  exposure  is  inva- 
riably longer.  This  discovery,  made  by  Dr.  Walters,  is  one  of  the  greatest  steps 
in  advance,  it  being  now  possible  to  take  advantage  of  that  most  efficient  and 
admirable  interrupter,  the  Wehnelt  electrolytic.  It  is  now  possible  by  means 
of  this  interrupter  and  coils  of  modern  construction  to  get  good  radiographs  of 
the  deeper  parts  of  the  body  in  a  few  seconds — a  very  brief  time  when  com- 
pared with  the  period  of  several  minutes  reciuired  by  the  older  apparatus. 

The  interrupter  used  by  the  writers  consists  of  a  piece  of  lead  pipe  one  and 
three-fourths  inches  inside  diameter,  three-sixteenths  inch  thick,  and  aljout 
twelve  inches  long.  This  is  fastened  to  a  board  by  cutting  two  ears  or  lugs, 
bending  them  back  and  screwing  the  same  to  the  board.     A  hole  is  now  cut 


Fig.  179. — Interrupter  Board  with  Lead  and  Glass  Tube  attached.  Tlic  .spiral  wire,  1,  is  attached 
to  the  lead  pipe.  The  loop,  2,  is  attached  to  the  platinum  wire.  A  slot  is  cut  in  the  lead  pipe  close 
to  the  board  for  the  outlet  of  the  glass  tube,  which  is  inside  the  lead  pipe.  The  latter  is  12  inclies  long, 
with  an  inside  diameter  of  1^-  inches.  Liquid  in  stone  crock  comes  to  within  one  inch  of  outlet  of  glass 
tube.      (Original.) 


through  the  board  corresponding  to  the  centre  of  this  lead  tube  (Fig.  179).  Into 
this  hole  a  glass  tube  ten  inches  long  and  one-half  inch  inside  diameter  is  placed. 
To  the  lower  end  of  this  tube  a  capillary  tube  one  and  one-half  inch  long 
is  sealed,  this  capillary  l^eing  for  the  platinum  wire  to  pass  through.  This 
tube  has  a  side  outlet,  two  inches  from  the  top,  to  allow  the  liquid,  which  always 
rises  in  the  tube  when  the  interrupter  is  running,  to  pass  out,  otherwise  it  would 
overflow  on  to  the  cover.  A  copper  wire,  sixteen  inches  long,  is  now  taken, 
and  to  one  end  of  it  a  piece  of  iridized  platinum  four  inches  long  is  fastened. 
By  flattening  the  end  of  the  copper  wire  slightly,  a  small  hole  may  be  bored  in 
it  and  the  platinum  wire  passed  through,  bent  over,  and  then  soldered  securely 
in  place.     The  copper  wire  is  passed  through  a  cork,  which  is  fitted  tightly  into 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


605 


the  glass  tube.  Special  care  should  be  taken  to  prevent  the  platinum  from 
coming  in  contact  with  the  lead  pipe. 

The  board  with  the  tube  attached  is  now  put  in  a  stone  crock  large  enough 
to  hold  from  one  to  six  gallons.  Six-gallon  stone  crocks  are  used  with  the 
interrupter  illustrated  in  Figs.  179  and  180;  and  the  fluid  to  be  used  is  either  sul- 
phuric acid,  specific  gravity  1.20,  or  a  half -saturat- 
ed solution  of  magnesium  sulphate  acidified  with 
sulphuric  acid.  This  magnesium-sulphate  solution 
was  suggested  by  E.  Hauser,  of  Madrid,  and  has  been 
used  at  the  Massachusetts  General  Hospital  for  eight 
months  without  being  renewed.  The  objection  to 
the  Wehnelt  interrupter,  on  the  ground  that  the  solu- 
tion gets  overheated  (that  is,  above  90°  F.),  seems  to 
be  obviated  to  a  great  extent  by  means  of  this  solu- 
tion ;  for  we  have  employed  it  day  after  day,  and  on 
testing  have  found  it  to  be  115°  F.,  which  high  tem- 
perature does  not  interfere  with  its  efficient  action. 

The  acid  or  the  magnesium-sulphate  solution  used 
in  the  interrupter  should  be  covered  with  some  heavy 
oil,  such  as  dynamo  oil,  to  the  extent  of  about  one- 
eighth  of  an  inch  deep.  This  prevents  evaporation 
of  the  liquid  and  also  the  spraying  which  always  oc- 
curs to  some  extent  when  heavy  currents  are  used. 

As  before  stated,  the  amount  of  current  passing 
into  the  primary  circuit  is  dependent  upon  the 
amount  of  platinum  or  anodal  surface  that  comes 
in  contact,  through  the  glass  tube,  with  the  liquid. 
On  the  coil  used  at  the  Massachusetts  General  Hos- 
pital, where  a  direct  current  of  two  hundred  and 
twenty  volts  is  used,  one-quarter  of  an  inch  of  plat- 
inum of  the  size  one  forty  thousandth  gives  three 
and  one-half  amperes;  three-quarters  of  an  inch  will 
give  eleven  amperes;  and  one  inch  fifteen  amperes. 
These  figures  cannot  be  taken  as  a  guide,  however, 
because  so  much  depends  on  the  resistance  in  the 
primary  as  well  as  in  the  secondary  circuit. 

To  connect  up  the  Wehnelt  interrupter  it  is 
necessary  to  determine  the  positive  terminal  of  the 

mains.  To  do  this,  we  advise  taking  a  dilute  solution  of  potassium  iodide, 
moistening  a  piece  of  filter  paper  with  it,  then  bringing  both  wires  into 
contact  with  the  filter  paper,  great  care  being  taken  not  to  allow  the  wires 
to  touch  each  other.     If  a  dilute  solution  is  used  the  iodine  will  be  liberated 


Fig.  ISO. — Interrupter  tube. 
Length,  lOJ  inches ;  inside  di- 
ameter, i  inch.  To  the  larger 
tube  is  sealed  a  capillary  tube, 
IJ  inch  long,  through  which  a 
platinum  wire  slides.  This 
capillary  tube  is  large  enough 
to  carry  the  platinum  wire 
without  friction.      (Original.) 


606  AMERICAN   PRACTICE   OF   SURGERY. 

and  a  blue  color  will  become  evident  at  the  positive  pole.  If,  however,  a 
strong  solution  is  used  a  brown  color  will  appear  at  the  positi-\-e  pole  and 
sometimes  this  may  be  confused  with  the  charring  of  the  paper  which  oc- 
curs quite  frequentty  at  the  negative  pole.  For  this  reason  a  dilute  solution 
is  advised.  After  it  has  been  determined  which  is  the  positive  pole  it 
should  be  connected  directlj^  to  the  platinum  terminal  of  the  interrupter. 
The  other,  or  negati^'e,  terminal  is  connected  to  the  primarj^  of  the  coil,  the 
other  end  of  the  primary  being  connected  to  the  lead  of  the  interrupter  (see  Fig. 
179).  The  interrupter  having  now  been  connected  at  all  points,  it  is  necessary  to 
find  out  the  amount    of   amperage  that    ^^■ilI    be  needed    for    operating    each 


Fig.  ISl. — -Y-ray  Room  of  [Massachusetts  General  Hospital,  showing  closet  containing  interrupters; 
on  top  of  closet  is  the  switchboard  with  knife  switches,  ammeter,  and  fuses.  Fuses  are  of  lower  resist- 
ance than  main  fuses,  so  that  when  fuse  blows  out  it  maj'  be  replaced  without  the  annoyance  of  going 
to  main  board,  which  may  be  in  the  cellar  or  at  some  distance.  The  operator  works  behind  a  screen, 
which,  in  this  picture,  has  been  pushed  to  one  side.      (Original) 

particular  apparatus.  From  experiments  on  se\Tral  coils  ^^"e  have  ascertained 
that  from  twelve  to  fifteen  amperes,  with  t^A'o  huntlred  and  t\A-ent3-  or  one  hundred 
and  ten  volts  of  a  direct  current,  will  be  found  sufficient  for  all  radiographic 
work,  a  rheostat  being  used  to  control  the  amount  of  current  fiowing  into  the 
primary  circuit.  A  lower  voltage,  if  available,  is  recommended,  from  si.xty  to 
ninety  volts  being  considered  the  best. 

The  crude  interrupter  described  abo^■c  is  by  no  means  meant  to  take  the 
place  of  the  more  elaborate  and  easily  adjusted  apparatus  now  on  the  market, 
but  its  simplicity  of  construction  and  the  fact  that  we  have  had  several  inter- 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


607 


rupters  of  this  tj'pe  in  use  for  over  a  year  justify  us,  we  think,  in  furnishing 
dimensions  (Figs.  179  and  180). 

We  have  spoken  of  the  rheostat  controlhng  the  amount  of  current  that 
goes  into  the  primary  circuit,  and  we  feel  that  we  are  justified  in  saying  tliat 
without  it  we  cannot  get  the  Ijest  results  obtainable  from  an  efficient  and  always 


Fig.  182. — Coil  showing  mechanical  interrupter,  also  switchboard  with  switches,  rheostat,  and 
meters.  Wehnelt  interrupter  can  be  placed  in  closet  below.  Tlie  writer  believes  that  a  better 
arrangement  is  to  have  the  .switchboard  at  a  distance  from  the  coil  and  tube  stand.  3y  this  plan  the 
operator  may  always  have  the  protective  screen  interposed  between  him  and  the  active  tube.  (See 
also  Fig.  ISl.) 


satisfactory  apparatus.  To  have  sufficient  platinum  exposed  in  the  liquid  to 
give  fifteen  amperes  in  the  primary  circuit,  ^^■ithout  a  rheostat  to  control  it,  is, 
to  say  the  least,  a  somewhat  dangerous  proceeding;  for,  although  the  spark 
from  a  large  induction  coil  may  not  cause  harmful  effects  if  received  by  the 
patient,  it  is  certainly  sufficient  to  make  him  hesitate  as  to  the  advisability  of 
again  submitting  himself  to  such  an  examination.     The  rheostat  gives  the 


608  AMERICAN  PRACTICE  OF  SURGERY. 

operator  complete  control  of  the  current  passing  into  the  coil.  By  this  means 
he  can  use  more  or  less  according  to  the  vacuum  of  the  tube;  moreover,  if  he 
uses  the  rheostat  instead  of  the  switch  when  shutting  off  the  coil,  all  danger 
of  the  patient  getting  a  shock  is  ob^'iated.  In  our  work  we  are  accustomed 
to  use  a  twenty-ampere  rheostat  with  one-half  or  one-ampere  steps.  With 
this  fine  gradation  the  operator  has  great  control  over  the  amount  of  current 
going  into  the  primarj^  circuit.    (Figs.  181  and  182.) 

If  the  alternating  current  is  the  source  of  supply,  a  coil  may  be  operated  to 
good  advantage  by  using  the  Wehnelt  interrupter,  or  better  by  using  in  series 
with  this  interrupter  the  aluminum  rectifier,  tlms  converting  the  alternating  into 
the  direct  current.  It  is  not  cpite  so  easily  managed  as  a  coil  operated  on  the 
direct  current,  but,  if  care  be  taken  to  keep  the  twenty-per-cent  aqueous  solu- 
tion of  ammonium  phosphate  alkaline,  good  results  may  be  readily  obtained 
from  this  rectifier.  If  expense  is  not  to  be  considered,  a  motor  converter  is  to 
be  by  all  means  recommended.  Storage  batteries  may  be  used  provided  they 
be  large  enough  to  give  sixtv  volts  or  over.  For  this  purpose  the  storage  bat- 
.  tery  of  an  automobile  may  be  utilized,  and  the  aluminum  rectifier  may  be  used 
for  charging  the  storage  batter}'.  Many  operators  prefer  the  static  machine, 
and  there  is  certainly  much  to  be  said  in  its  favor.  In  order  to  get  good  results 
from  static  machines  a  large  one  capable  of  being  driven  at  a  high  rate  of  speed 
is  necessary.  This  type  of  apparatus  has  been  greatly  developed  since  the 
advent  of  Roentgen's  discovery,  and  the  objection  to  the  influence  of  atmos- 
pheric conditions  has  been  in  large  measure  eliminated.  The  static  machine  will 
give  beautiful  radiographs,  is  by  no  means  as  hard  on  the  tubes,  and  is  much 
simpler  to  operate.  The  objection  to  it  is  the  liability,  in  damp  weather,  or 
when  operated  in  certain  climates,  of  failure  to  start  even  after  much  manipu- 
lation. Another  objection  is  the  time  of  exposure  required.  Much  longer 
exposures  are  necessary  than  with  the  coil.  Still,  many  operators  prefer  it  to 
the  coil  and  get  beautiful  results. 

Tube. 

The  type  of  tube  should  be  adapted  to  the  machine.  It  is  advisable  to  use 
small  tubes  on  coils  of  short  spark  length,  and  large  tubes  on  coils  giving  long, 
heavy  discharge.  The  tubes  used  by  the  writers  are  of  the  Gundelach,  Voltholm, 
and  Friedlander  tj-pe. 

To  accurately  describe  the  appearance  of  an  .T-ray  tube  as  the  process  of 
seasoning  or  ageing  progresses  seems  almost  impossible.  The  illustrations  used 
by  the  writers  (Plate  V.)  are  intended  to  emphasize  the  more  important  visi- 
ble changes  that  the  tube  undergoes  during  the  time  of  ageing,  which  ageing 
we  believe  to  be  essential  to  good  results. 

A^^ien  an  x-ray  tube  is  used  for  the  first  time  it  usually  is  of  high  resistance. 


EXPLANATION  OF  PLATE  V. 

Fig.  1. — Illustrates  an  Unseasoned  High-Vacuum  Tube.  With  12  amperes  on  primary  circuit 
only  0.5  to  1  miliiammeter  can  be  forced  through  the  tube.  Radiographs  taken  under  such  conditions 
give  thin  plates  showing  practically  no  contrast  between  bone  and  flesh.  Lowering  the  vacuum  of  this 
tube  will  increase  the  radiographic  value,  but  only  temporarily,  as  the  tube  is  unseasoned,  and  will  soon, 
even  with  short  exposures,  present  an  appearance  such  as  is  illustrated  in  Fig.  2.  A  seasoned  tube  may 
present  an  appearance  similar  to  this. 

Fig.  2. — Illustrates  a  Low-Vacuum  Tube.  The  tube,  under  such  conditions,  is  of  very  little  value 
for  radiographic  work.  It  is  very  important  to  note  that  when  the  tube  is  in  this  state,  showing  cathode 
stream,  we  get  a  very  high  reading  on  miliiammeter  with  comparatively  little  energy  flowing  into  the  pri- 
mary circuit.  This  may  be  due  not  so  much  to  the  degree  of  vacuum  as  to  what  gases  the  vacuum  is 
composed  of.  In  unseasoned  tubes  we  have  gases  driven  off  from  terminals,  whereas  in  seasoned  tubes 
the  vacuum  is  reduced  by  means  of  the  regulator. 

Fig.  3.— Illustrates  the  Appearance  of  the  Tube  when  Working  to  the  Best  Advantage.  Notice  the 
illuminated  spot  on  the  anode,  which,  although  not  essential,  does  seem  to  indicate  increased  radiographic 
value.  In  order  to  get  high  reading  on  the  miliiammeter  with  this  tube,  when  used  on  coil  giving  spark 
as  illustrated  in  Fig.  178,  it  is  necessary  to  use  at  least  12  amperes  on  the  primary;  parallel  spark  gap 
resistance  being  6  to  7  inches,  and  miliiammeter  reading  between  6  and  8  milliamperes.  The  average 
exposure  for  adult  hip,  under  such  conditions,  is  from  20  to  40  seconds. 

Fig.  4. — Illustrates  a  Tube  that  Shows  an  Inverse  Discharge.  Under  such  a  condition  the  fluo- 
roscope  will  be  briUiantly  illuminated,  but  the  radiograph  will  be  flat;  that  is,  it  will  lack  contrast  be- 
tween bone  and  tissue,  and  the  definition  will  also  be  vc*ry  poor.  It  is  very  important  to  note  here  that 
the  miliiammeter,  wl.en  the  tube  is  in  this  condition,  will  read  zero;  yet  we  may  have  exactly  the  same 
condition  in  the  primary  circuit  as  exists  wiien  the  tube  presents  an  appearance  such  as  is  illustrated  in 
Fig.  3  of  the  present  plate.  The  inverse  discharge  is  so  great  that  direct  a:-ray  reading  is  completely 
wiped  out.  This  inverse  discharge  may  be  overcome  to  quite  an  extent  by  using  a  series  spark  gap 
or  ventral  valve  tube,  by  lowering  the  vacuum  by  means  of  the  regulator  and  then  raising  self-induc- 
tion of  the  primary.  It  is  advisable  not  to  operate  the  tube  when  it  presents  this  condition,  as  the 
tube  then  becomes  blackened  and  overheated.  Overcome  the  tendency  of  the  coil  to  produce  this  con- 
dition by  the  means  suggested,  viz..  by  the  series  spark  gap  or  ventral  valve  tube.  Some  coils  will 
operate  much  better  if  the  spark  gap  is  kept  constantly  in  series  with  the  tube. 


American   Practice  of  Surgery. 


F.  AILKER    DEL 


Stages  in  "Ripening"  or  "Seasoning"  X-Ray  Tubes 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  609 

and  the  discharge  will  jump  across  an  air  gap  of  5  to  7  inches  as  estimated  by 
means  of  parallel  spark  rods,  with  which  nearty-all  coils  are  equipped.  Under 
such  conditions  the  tube  should  be  lowered  by  means  of  the  regulator,  that  is, 
by  allowing  the  discharge  to  pass  through  the  chemical  or  by  heating  the  pala- 
dium  regulator  if  of  the  osmosis  variety.  This  allows  gas  to  pass  into  the  tube, 
and  in  this  manner  lowers  the  resistance.  If  the  current  is  now  turned  on  in  suf- 
ficient quantity  the  tube  will  glow  with  an  apple-green  fluorescence.  Bright  flu- 
orescent spots  oftentimes  appear  on  different  parts  of  the  tube;  this  appearance 
may  last  for  several  minutes  if  only  a  small  amount  of  energy  is  allowed  to  pass 
through  the  coil.  If,  however,  heavy  discharges  are  sent  through  the  coil,  this 
condition  soon  changes  in  a  new  imseasoned  tube  with  the  Wehnelt  interrupter, 
and  a  warning  note  is  invariably  heard  just  previous  to  this  change,  and  the 
expert  knows  that  the  resistance  of  the  tube  is  about  to  fall  very  rapidly  unless 
the  current  is  diminished  or  shut  off  completely.  If  the  current  is  shut  off  just 
previous  to  this  fall  in  resistance  or  lowering  of  vacuum,  and  the  tube  allowed  to 
cool  completely,  this  process  may  be  repeated  many  times;  but  if  the  current  is 
not  shut  off  and  the  tube  is  allowed  to  run,  the  anode  becomes  hot,  blue  vapor  ap- 
pears in  the  bulb,  the  color  changes  to  a  more  yellow-green,  and  then  there  is  seen 
a  stream  of  bluish  vapor  between  the  cathode  and  anode.  At  first,  this  stream 
impinges  on  the  anode,  but  as  the  vacuum  gets  lower  it  will  be  seen  that  the  cone- 
shaped  stream  changes  and  apparently  two  cones  are  formed  having  the  apices 
midway  between  the  anode  and  the  cathode  (Fig.  2,  Plate  V.).  This  blue  stream 
is  known  as  the  cathode  stream.  Just  previous  to  this  double-cone  appearance 
the  anode  becomes  very  hot.  The  radiographic  value  is  greatly  increased,  then 
there  is  a  sudden  and  greatly  diminished  radiographic  value.  The  anode  appears 
less  hot,  and  finally  the  tube  becomes  completety  filled  with  blue  vapor.  Dur- 
ing the  latter  part  of  this  condition  a  stream  of  blue  vapor  may  oftentimes  be 
seen  starting  from  the  anode  and  apparently  striking  the  glass  either  in  a  line 
perpendicular  to  the  face  of  the  anode  or  at  right  angles  to  the  cathode  stream. 
Where  this  blue  stream  strikes,  the  anode  is  said  to  be  the  source  of  x-ray  light. 
Such  a  tube  is  of  very  little  value  for  radiographic  work,  but  if  properly  treated 
the  process  of  seasoning  will  go  on  and  eventually  the  tube  will  present  an  appear- 
ance very  much  like  that  sho'mi  in  Fig.  .3,  Plate  V.  A  beautiful  rich  yellow 
with  a  sharp  line  of  demarcation  divides  the  tube  into  two  distinct  parts;  a 
brightly  illuminated  spot  showing  on  the  anode  if  the  current  is  powerful  enough. 
This  bright  spot  is  caused  by  the  cathode  stream  striking  the  anode,  and  in  a 
perfectly  focussed  tube  covers  an  area  of  about  one-sixteenth  of  an  inch.  If  it 
is  much  larger  than  one-sixteenth  of  an  inch  in  diameter,  except  under  conditions 
described  under  low-vacuum  tube  (Fig.  2,  Plate  V.),  it  shows  that  the  tube  has 
not  been  accurately  focussed,  and  radiographs  taken  with  such  tubes  lack  the  fine 
definition  so  necessary  to  good  plates.  If  the  spot  is  smaller  than  about  one-six- 
teenth of  an  inch  the  bombardment  of  the  cathode  stream  has  so  much  force  that 
VOL.  I.— 39 


610  AMERICAN   PRACTICE   OF   SURGERY. 

the  anode  -u-ill  be  punctured  if  of  light  weight;  if  the  anode  is  of  a  heavy  type, 
as  is  the  case  in  the  tubes  used  by  the  writers,  the  face  of  the  anode  will  be 
fused  at  this  point,  eA'^en  with  short  exposure.  Wien  the  tube  reaches  this  stage 
(Fig.  3,  Plate  Y.)  it  is  of  great  value  for  radiographic  work,  although  by  no  means 
fully  seasoned.  The  process  of  seasoning,  if  properly  managed,  goes  on  from 
this  point  until  we  get  a  tube  the  color  of  which  changes  to  that  of  a  more  yel- 
lowish-green resembling  that  of  Fig.  1,  Plate  V.,  except  that  the  color  is  richer 
and  the  fluorescent  spots  are  not  so  persistent  if  at  all  present.  Wlien  the  tube 
reaches  this  last  stage,  which  may  take  several  weeks  of  daily  use,  it  should  be 
carefully  tested  and  labelled,  as  it  is  now  the  tube  needed  for  radiographs  of  the 
deeper  parts.  During  this  process  of  seasoning  many  interesting  and  remarkable 
phenomena  may  be  observed.  One  of  the  most  striking,  after  that  demonstrated 
in  Fig.  2,  Plate  V.,  is  the  condition  of  very  high  resistance  which  all  tubes  seem 
to  pass  through  if  kept  in  use  long  enough.  The  tube  glows  with  this  character- 
istically beautiful  color  when  started  up  for  a  few  seconds,  then  suddenly  it 
seems  as  though  a  deep  inspiration  had  occurred,  for  usually,  without  any  warn- 
ing whatsoever,  the  glow  disappears  and  there  is  a  loud  roar  in  the  interrupter; 
and  even  if  more  current  is  sent  through  the  tube  it  cannot  be  started  up  again 
without  lowering  the  vacuum.  This  is  probably  caused  by  the  complete  exhaus- 
tion of  the  terminal  of  occluded  gases  as  well  as  by  the  using  up  of  the  original 
vacuum.  ^Vlren  the  tube  reaches  this  condition  it  is  necessary  to  lower  the 
vacuum  more  frequently  than  before,  by  means  of  the  chemical  regulator.  The 
tube  seems  to  be  able  to  take  care  of  large  quantities  of  liberated  gases.  It 
has  been  noticed  by  the  writers  oftentimes  that  the  whole  tube  will  be  filled 
with  a  bluish  ^'apor  which  will  instantly  disappear,  and  the  beautiful  richgreen- 
ish-j'ellow  take  its  place.  When  the  tube  reaches  this  condition  we  consider  it 
of  the  greatest  radiographic  value,  it  being  capable,  when  properly  operated, 
of  giving  good  radiographs  with  very  short  exposure ;  also  definition  is  greatly 
increased  and  there  is  very  little  diminution  in  the  contrast  so  noticeable  when 
using  a  yellow  tube,  as  illustrated  in  Fig.  3,  Plate  Y.  To  accomplish  this  process 
of  seasoning  and  ripening  an  x-ray  tube,  weeks  of  careful  manipulation  during 
the  daily  routine  work  will  be  recjuired,  and  it  is  possible  to  ruin  all  chances  of 
ever  bringing  this  condition  about  unless  the  operator  appreciates  certain  basic 
principles  in  the  proper  manipulation  of  .r-ray  tubes.  The  temptation  to  beat 
all  records  for  x-ray  exposure  is  probably  the  cause  of  so  many  failures.  To  illus- 
trate how  necessary  a  sufRcient  length  of  exposure  is,  let  us  take  the  ordinary 
photographic  process.  Is  it  possible  to  get  the  best  results  of  interiors  or  of 
subjects  in  which  there  is  a  variety  of  values  as  to  light  and  shade  by  a  short 
exposure?  A  short  exposure  of  such  a  subject  will  usually  produce  a  negative 
which  shows  under-exposure  of  the  deeper  shadows.  We  think  the  same  holds 
true  in  taking  radiographs  of  the  deeper,  thicker  parts  of  the  body  and  even  of 
the  extremities.     We  should  remember  that  it  takes  time  for  the  x-ray  light  to 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  611 

pass  through  the  part  exposed  to  the  phiotographic  plate,  and  that  the  different 
parts  of  the  body  have  different  degrees  of  power  to  absorb  light.  If  we 
can  appreciate  this  important  fact,  our  failures  in  this  line  of  work  will  be  fewer 
in  number  and  our  successes  greater  and  more  valuable. 

Another  condition,  one  of  the  most  annoying  and  very  common,  is  the  ten- 
dency which  some  x-ray  tubes  have  to  be  greatly  influenced  by  the  inverse  dis- 
charge— an  influence  which  is  manifested  by  the  appearance  of  several  rings  back 
of  the  anode,  also  throughout  the  entire  tube.  In  addition  to  this  the  whole  tube 
takes  on  the  yellow  fluorescence,  and  the  line  of  demarcation  so  characteristic  of 
tubes  when  operated  to  the  best  advantage  is  very  faint.  This  condition  may  be 
overcome  to  a  great  extent  by  the  use  of  the  series  spark  gap  so  universally 
adopted.  The  spark  gap  used  by  the  writers  is  the  multiple  spark  gap  introduced 
by  Dr.  Francis  Williams,  of  Boston.  Some  coils  are  so  constructed  that  this  in- 
verse di^rcharge  is  great  enough  to  jump  several  inches,  as  indicated  by  the  fact 
that  when  this  condition  does  occur  in  a  tube  it  may  be  overcome  by  pulling  the 
series  spark  gap  out  until  the  sharp  anode  line  appears  again.  This  condition  of 
tube  is  illustrated  in  Fig.  4,  Plate  V.  During  this  stage  the  fluoroscope  is  bril- 
liantly illuminated,  and  it  is  possible  to  get  radiographs  of  even  the  deeper  parts 
with  tubes  in  this  concUtion,  but  they  lack  contrast  and  detail.  The  soft  parts 
cannot  be  differentiated,  and,  except  for  the  almost  entire  lack  of  detail,  plates 
taken  under  such  conditions,  resemble  those  which  are  taken  with  the  high 
vacuum  tube.  This  condition  usually  occurs  just  before  the  vacuum  drops, 
when  the  steady  hum  of  the  Wehnelt  interrupter  changes  to  the  irregu- 
lar roar.  It  may  be  overcome  to  a  great  extent  by  lengthening  the  series  spark 
gap  and  turning  off  some  of  the  current.  If  you  are  fortunate  enough  to  have  a 
coil  with  variable  primary  inductance,  the  difficulty  may  be  almost  completely 
eliminated  by  using  a  higher  self-induction  in  the  primary,  two  or  more  layers 
according  to  the  degree  of  vacuum. 

Following  is  a  brief  account  of  the  important  steps  in  the  process  of  season- 
ing tubes  as  used  by  the  writers.  Before  giving  this  account,  however,  we  shall 
take  the  liberty  of  telling  what  we  think  to  be  some  of  the  causes  of  so 
many  tubes  being  ruined  long  before  they  have  passed  through  the  successive 
stages  described  above.  The  desire  to  get  short  exposure,  and  the  lack  of  the 
appreciation  of  the  fact  that  an  x-ray  tube  is  an  exceedingly  delicate  piece  of 
apparatus,  are  responsible  for  many  fadures.  To  connect  up  an  x-ray  tube, 
close  the  circuit,  turn  on  the  rheostat,  and  use  the  full  capacity  of  the  coil,  par- 
ticularly on  a  new  tube  in  an  endeavor  to  get  a  short  exposure,  is  a  serious  mis- 
take. You  may  succeed  in  getting  a  few  good  radiographs,  but  invariably  the 
tube  will  go  to  pieces,  blue  vapor  and  the  blue  cone  will  appear,  as  illustrated  in 
Fig.  2,  Plate  V.,  and,  for  the  time  being  at  least,  the  tube  is  useless. 

When  a  new  tube  is  received  it  is  tested  by  the  following  method:  After 
being  connected  to  the  coil  the  current  is  turned  on  and  the  resistance  of  the 


612  AMERICAN  PRACTICE  OF  SURGERY. 

tube  noted  by  means  of  the  parallel  spark  gap  or  millianmieter.  If  the  tube  lights 
up  with  yellow  color,  as  in  Fig  3,  Plate  V.,  the  current  is  turned  off  at  once  and 
the  tube  tested  radiographically  or  by  means  of  the  milliammeter  in  series  with 
the  tube  as  described  later.  If  the  tube  gives  an  appearance  like  that  shown  in 
Fig.  1,  Plate  V.,  more  current  is  turned  on ;  if  fluorescent  spots  still  persist  and  the 
color  is  green,  the  tube  is  lowered  by  means  of  a  chemical  or  a  palladium  regula- 
tor. If  a  palladium  regulator  is  used  we  employ  an  alcohol  lamp  with  very  small 
flame,  the  lamp  being  attached  to  a  wooden  stick  four  or  five  feet  long,  as  advised 
by  Dr.  Rollins,  of  Boston.  Palladimn  takes  hydrogen  from  the  flame,  and  this 
hydrogen  passes  into  the  tube  and  lowers  the  resistance.  We  consider  this  a 
most  delicate  and  satisfactory  regulator.  After  the  resistance  is  lowered  to 
such  a  degree  that  the  tube  has  the  appearance  of  that  illustrated  in  Fig.  3, 
Plate  v.,  it  is  tested  radiographically  or  by  means  of  the  meter  in  secondary 
circuit.  We  have  spoken  of  a  stage  in  which  the  tube  presents  the  appearance 
shown  in  Fig.  3,  Plate  V.,  but  we  should  at  the  same  time  call  attention  to  the 
fact  that  many  tubes  will  resemble  this  in  color,  and  yet  be  far  from  sea- 
soned. We  must  say,  however,  that  the  tendency  of  the  manufacturers 
to-day  is  to  at  least  partially  season  tubes  before  shipping:  this  is  done  by  run- 
ning them  on  a  coil  during  the  process  of  exhaustion,  and  the  practice  is  much  to 
be  commended.  If  the  tube  is  of  low  resistance  (see  Fig.  2,  Plate  V.)  the  following 
method  is  adopted :  The  vacuum  being  low  it  is  necessary  to  increase  or  raise 
it.  If  the  coil  has  variable  primary  inductance,  raise  the  self-induction  of  the 
primary.  In  many  instances  a  tube  may  be  made  useful  for  ratliographic  work  by 
this  means.  The  series  spark  or  ventral  tube  may  be  tried,  but  we  believe  it  is 
better  to  begin  the  process  of  seasoning  and  proceed  as  follows:  the  tube  is 
allowed  to  run  with  a  small  amount  of  cm'rent,  only  sufficient  to  bring  the  tube  to  a 
dull  glow ;  this  is  to  be  continued  for  about  twenty  minutes,  then  more  current  is 
to  be  turned  on  until  blue  vapor  just  appears;  the  tube  is  noAV  allowed  to  cool 
and  the  process  repeated  several  times.  If  the  operator  is  doing  therapeutic 
work,  this  type  of  tube  may  be  used  to  advantage  on  certain  cases  and  the  process 
of  seasoning  hastened  in  this  way.  After  the  tube  has  reached  such  a  stage,  re- 
sembling that  of  Fig.  3,  Plate  V.,  it  is  tested  for  radiographic  value.  We  do  not 
consider  it  full}^  seasoned  when  it  presents  the  appearance  shown  in  this  figure, 
for  this  condition  may  be  only  temporary  and  the  terminals  and  the  other  parts 
of  the  tube  may  still  contain  the  gases  that  cause  the  vacuum  to  drop  when 
overloaded  or  heated. 

Radiographic  Tests. 

We  have  said  that  the  tube  should  be  tested  radiographically,  or  by 
means  of  the  milliammeter,  in  secondary  circuit,  with  the  tube.  It  will  be 
noticed  that  fluoroscopic  means  of  measuring  x-ray  light  have  not  been 
referred  to.      For    several   years   the  fluoroscope  has   been    completely    dis- 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  613 

carded  by  the  writers  except  for  the  location  of  foreign  bodies  and  in  chest 
examinations.  Many  times  during  tlie  earlier  days  of  .r-ray  worlv  it  was 
observed  that,  wliile  the  fluoroscopic  picture  was  exceedingly  beautiful,  the 
plates  were  of  almost  no  value.  After  we  had  learned  to  judge  the  value 
of  the  tube  by  its  appjarance  our  results  steadily  improved.  Having  studied 
the  fluoroscopic  picture  under  all  its  varying  changes,  and  having  taken 
hundreds  of  plates  during  these  changes,  we  feel  compelled  to  say  that  this  instru- 
ment is  most  umeliable.  Even  the  ingenious  devices,  such  as  the  skiameter,  must 
be  included  in  this  sweeping  statement.  To  say,  when  one  is  taking  a  radiograph 
of  a  suspected  renal  calculus  in  a  patient  weighing  one  hundred  and  fifty  pounds, 
that  the  skiameter  furnishes  a  certain  reading,  does  not,  as  we  believe,  convey 


A  B 

Fig.  183. — Two  Fluoroscope.s  Used  bj^  the  Writers  for  Different  Purposes.     (Original.) 

.4  illustrates  fluoroscope  employed  in  making  examinations  of  the  cliest  or  in  searching  for  foreign 
bodies. 

B  represents  an  instrument  formerly  used  when  testing  tubes.  A  skeleton  hand  is  fastened  on  the 
bottom  of  the  screen  which  is  covered  with  black  cloth.   This  instrument  was  discarded  several  years  ago. 

1  is  a  sheet  of  lead  J  in.  thick,  painted  with  several  coats  of  white  lead  paint ;  2  is  a  sheet  of 
aluminum  \  in.  thick  and  is  large  enough  to  protect  the  face  of  the  operator;  this  is  painted  with 
several  coats  of  white  lead.  Inside  the  top  of  the  fiuoroscope  is  set  a  piece  of  lead  glass,  \  in.  thick, 
to  protect  the  eyes. 

information  of  value  to  anybody  except  the  person  who  is  conducting  the  oper- 
ation, and  even  he  will  be  in  error  sometimes.  The  fluorescent  screen  is  dete- 
riorating slowly  but  surely;  the  operator  can  at  certain  times  make  a  better 
observation  than  at  others,  and  what  is  to  one  observer  a  briUiant  screen  with 
black  or  gray  bones  or  clear  areas  in  the  skiameter,  may  not  be  so  to  others. 
Then  the  all-important  factor  of  the  distance  of  the  screen  from  the  tube  is  often- 
times forgotten  or  neglected.  We  must  remember  that  the  value,  both  fluoro- 
scopically  and  radiographically,  increases  inversely  as  the  square  of  the  distance. 
One  of  the  very  important  objections  to  the  use  of  the  fluoroscope  for  such  pur- 
poses is  the  danger  to  the  operator.  Fig.  183,  A,  illustrates  an  instrument  that 
has  been  in  use  for  several  years  by  the  writers;  it  is  described  as  a  protective 


614  AMERICAN   PRACTICE   OF   SURGERY. 

fluoroscope,  and  we  still  continue  to  use  it  when  we  have  need  of  making  such 
examuaations. 

Tlie  method  used  for  testing  tubes  is  the  following ;  After  trj'ing  a  tube  in 
the  mamier  described  above,  apply  the  radiographic  test.  This  consists  in 
taking  a  radiograph  of  some  subject  that  resembles,  at  least  in  its  chemical 
structure,  the  hmnan  bod}-.  For  this  purpose  the  hind  quarter  of  a  good-sized 
sheep  is  often  emplo}'ed;  this  may  be  so  cut  that  only  enough  to  cover  a  6J  by 


Fig.  1S4. — Illustrates  specimen  used  when  testing  tubes.  Exposure  10  seconds,  distance  20  inches. 
MiUiammeter  reading  4  milhamperes ;  ammeter  in  primary  circuit  reading  12  amperes;  spark  resist- 
ance 6  inches.  Under  such  conditions  an  adult  liip  ■n'oxild  be  given  an  exposure  of  from  20  to  40  sec- 
onds, according  to  size  of  patient;  the  tube  being  at  the  same  distance  from  the  plate.      (Original.) 

Si-inch  plate  is  used.  (Fig.  184.)  This  is  then  placed  m  ten-per-cent  formalm  for 
about  ten  days.  It  may  be  used  fresh,  and  it  is  possibly  better  when  it  is  in  this 
state ;  but  for  the  operator  who  has  to  test  tubes  quite  frequently,  the  formalized 
specimen  is  more  practical.  After  it  has  been  removed  from  the  formalin 
solution  it  should  be  washed  and  then  placed  in  normal  salt  solution  to  which 
chlorinated  soda  in  the  proportion  of  1 :  50  has  been  added.  This  is  to  over- 
come to  some  extent  the  objection  that  a  dry  specimen  does  not  present  the 
same  conditions  as  the  li-\'ing.     The  writers  are  in  the  habit  of  using  a  dr}'  speci- 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  615 

men,  one  that  was  placed  fresh  in  a  formahn  solution  and  allowed  to  remain 
there  for  thirty  days;  it  is  well  preserved  and  in  no  way  offensive.  "\Mien  this 
specimen  is  employed  as  a  test,  a  piece  of  parchment  paper  is  placed  over  the 
plate  holder  and  an  exposure  is  made.  If  the  tube  will  take  a  thoroughly  satis- 
factory radiograph  of  this  specimen  m  from  five  to  ten  seconds  it  may  be  counted 
upon  to  take  a  good  radiograph  of  an  adult  hip  (160-pound  patient)  in  two  or 
three  times  that  length  of  time;  that  is,  in  from  ten  to  thirty  seconds.  We 
realize  that  this  test  is  of  a  rather  crude  character,  for  in  the  living  subject  the 


Fig.  185. — Radiograph  Showing  Renal  Calculi;  specimen  consists  of  a  block  of  beef  six  indies  thick, 
three  inches  wide,  and  six  inches  long;  kept  under  conditions  described  on  page  614.      (Original.) 

physical  conditions — the  movements  caused  by  the  circulating  blood,  the  amomrt 
of  fat  or  muscular  tissue  clothing  the  part,  etc. — -^-ary  enormously.  Neverthe- 
less, experience  has  taught  us  that  we  maj-  rely  upon  it  with  some  degree  of 
confidence.  For  abdominal  work — as,  for  example,  in  the  search  for  calculi — 
the  \\Titers  use  a  piece  of  beef  about  six  inches  square ;  on  the  top  of  this  are 
placed  capsules  of  gelatin  which  have  been  treated  with  formaldehyde,  thus 
rendering  them  insoluble;  these  capsules,  which  var}'  in  size  from  a  weight 
of  1  grain  to  one  of  15  grains,  contain  mixtures  of  calcic  phosphate,  calcic 
oxalate,  sodium  urate,  and  calcic  carbonate.  (Fig.  185.)  The  test  can  be  made 
still  more  perfect  by  introducing,  along  with  the  capsules,  a  thin  rubber  sac  con- 
taining partly  air  and  partly  water;  the  object  of  this  step  being  to  reproduce 
in  some  degree  the  conditions  which  actually  exist  in  the  living  subject.  The 
time  of  exposure  required  for  securing  a  satisfactor}^  radiograph  imder  the 
conditions  of  this  test  is  just  about  one-half  that  which  will  be  required  in  the 
case  of  a  living  human  being.  The  employment  of  such  a  test  will  generally 
save  the  operator  from  the  necessity  of  making  a  second  appointment  with  the 
patient. 


616 


AMERICAN  PRACTICE  OF  SURGERY. 


MlLLIAMMETER. 

Recently  there  has  been  perfected  an  instrument  kno-rni  as  the  ammeter 
for  x-ray  tubes;  we  refer,  not  to  the  hot-wire  meter,  but  to  the  one  invented 
by  Dr.  Snooks,  of  Philadelphia.  The  •n-riters  have  done  much  work  with  this 
instrmnent  and  offer  here  their  results.  We  believe  it  possible  to  utilize  this 
instrmnent  in  estimating  the  radiographic  value  of  x-ray  tubes.  This  meter 
measures  the  amount  of  current  passmg  into  the  tube,  indicates  a  rise  or  fall 
m  A'acurmi  A'ery  accurately,  and  warns  the  operator  at  once  of  the  presence  of 
that  harmful  and  annoving  condition  Icnowii  as  the  "mverse  discharge."     To 


Fig.  1S6. — Shows  Increased  Radiographic  Value  when  MilUanuneter  reads  Higher.  Meter  reading 
was  6  milliaraperes,  the  other  conditions  being  exactly  the  same  as  in  Fig.  187.  Increased  radio- 
graphic value  indicated  by  almost  complete  absence  of  soft  parts.  This  effect  could  not  be  accom- 
plished in  the  process  of  printing,  and  is  due  solely  to  increased  value  of  x-ray  light,  as  indicated  by 
higher  reading  on  miUianuneter.      (Original.) 

illustrate  this  test  we  will  take  an  apparatus  giving  a  10-inch  very  heavy 
flammg  spark  with  ammeter  on  the  primary  circuit  reading  12  amperes,  tube 
20  inches  from  the  plate.  A  new  tube  is  used;  it  is  found  to  be  of  high  resist- 
ance, the  meter  will  not  register  oA'er  1  miUiampere,  it  has  a  parallel  spark  resist- 
ance of  6  inches  or  more.  Tlie  vacuum  is  now  lowered.  (A  Gundelach  tube 
is  preferred  for  this  test,  as  the  regulation  of  its  vacumn  is  much  more  delicate 
and  the  vacuum  obtained  more  permanent.)  Tlie  ammeter  will  give  a  higher 
reading  at  once.  If,  however,  the  current  is  allowed  to  run  through  the  tube 
for  a  minute  or  two  it  will  be  noticed  that  the  indicator  begins  to  .swing  back 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  617 

and  forth,  sometimes  going  to  zero;  the  tube  during  this  stage  presents  the 
appearance  of  Fig.  4,  Plate  V.  This  swinging  of  the  indicator  is  caused  by 
the  "inverse  discharge,"  and  on  many  coils  it  may  be  overcome  completely 
by  the  use  of  the  series  spark  gap,  by  the  ventral  tube,  or  by  means  of  the  varia- 
ble primary  inductance.  If  the  current,  however,  is  allowed  to  run  on,  in  a  few 
seconds  the  picture  will  change;  the  tube  seems  to  quiet  dowii,  and  the  note 
in  the  interrupter  is  no  longer  mtermittent  and  unsteady,  but  gives  a  loud 
roar.  The  tube  is  faULng  in  vacuum;  it  becomes  blue,  and  the  cathode  stream 
is  seen.    At  this  point  it  is  interesting  to  note  that  the  milliammeter  will  show 


Fig.  187. — This  radiograph  was  made  with  the  milliammeter  reading  2  milliamperes,  the  anode 
24  inches  from  plate,  and  the  time  of  exposure  10  seconds;  developed  12  minutes.  Compare  with  Fig. 
186,  which  was  taken  under  the  same  conditions  exactly,  except  as  regards  the  reading  of  the  mil- 
liammeter, which  was  6  milliamperes.      (Original.) 

its  highest  rating.  We  wish  to  emphasize  the  fact  that  the  tube  has  the  same 
appearance  as  that  presented  in  Fig.  2,  Plate  V.— a  very  low  tube,  mifit  for 
radiographic  work,  and  yet  the  reading  of  the  ammeter  indicates  its  highest 
value.  It  is  at  this  point  that  the  amperage  on  the  iprimary  circuit  and  the 
parallel  spark  gap  should  be  observed;  it  will  be  found  that  the  meter  in  the 
secondary  circuit  reads  high,  while  that  in  the  primary  circuit  has  a  low  reading; 
also  that  the  parallel  spark  resistance  has  been  reduced  several  inches,  i.e.,  from 
6  or  7  to  ^  or  5.  This  condition  will  always  take  place  in  a  tube  that  is  un- 
seasoned or  in  one  that  has  been  overloaded.  This  high  reading  of  the  milli- 
ammeter does  not  indicate  high  radiographic  value;  that  is,  if  we  mean  by 


618 


AMERICAN  PRACTICE  OF  SURGERY. 


this  expression  (a:-ray  value)  the  property  of  affecting  photographic  plates. 
Eig.  2,  Plate  V.,  illustrates  this  condition  of  low  vacuum  tube,  giving  high  read- 
ing on  milliammeter.  When  a  seasoned  tube  is  used,  and  the  spark  resistance 
mid  amperage  on  the  primary  are  carefully  observed,  the  milliammeter  icill  be 
found  to  be  of  great  value. 


Fig.  188. 


Fig.  189. 


Figs.  ISS  and  189  represent  radiographs  taken  on  two  different  coils  under  exactly  the  same  con- 
flitions  of  distance  and  time,  with  miUiammeter  reading  the  same  in  both  exposures.  Notice  that 
racUographic  values  are  equal.  The  same  subject  is  used  in  Figs.  1S8,  189,  190,  and  191.  (Original.) 
Observe  that  these  plates  were  taken  on  different  coils,  but  with  same  meter  reading.  Other  conditions 
•were  e.xactlv  the  same. 


Fig.  190.  Fig.  191. 

Fig.  190  illustrates  high  radiographic  value  when  milliammeter  shows  high  reading — 5  seconds; 
I  milliamperes.     (Original.) 

Fig.  191  illustrates  low  radiographic  value  wlien  milhammeter  shows  correspondingly  low  reading 
—5  seconds;  1  milliampere.     (Original.) 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  619 

The  operator  is  invariably  warned  of  this  condition  by  the  swinging  of  the 
indicator  and  the  sound  of  the  interrupter  just  previous  to  lowering  of  the 
vacuum.  At  this  point  it  may  be  well  to  state  that  by  having  sufficient  self- 
induction  in  the  primar}^,  a  properly  balanced  coil,  and  service  derived  from 
a  direct  current  of  from  60  to  110  volts,  this  "inverse  discharge"  may  be  al- 
most completely  overcome. 

As  before  stated,  this  unseasoned  tube  must  be  worked  up  in  resistance. 
Label  the  tube  and  treat  it  as  suggested.  To  avoid  this  low  vacuum  it  is  neces- 
sary that  we  do  not  overload  the  tube  by  crowding  on  the  current  or  running 
it  for  a  long  time.  "\^lren  heating  the  palladium  we  should  stop  the  heating 
process  when  the  milliammeter  reads  two  milliamperes.  We  may  have  used  thus 
far  only  a  part  of  the  full  capacity  of  the  coil;  if  now  more  current  is  turned  on,  the 
meter  may  read  a  little  higher  or  remain  at  two.  Good  radiographs  of  even  the 
deeper  structures  may  be  taken  with  this  apparently  lo^^'  reading  if  a  seasoned 
tube  is  used.  The  process  of  seasoning  is  greatly  lengthened  by  the  use  of  tubes 
such  as  those  of  the  Gundelach,  Voltholm,  and  Friedlander  type,  owing  to  the 
large  amount  of  metal  in  the  anticathode  or  anode.  Our  observations  have  led 
us  to  firmly  believe  that  the  milliammeter  may  be  used  as  an  indicator  of  the 
radiographic  value  if ,  let  us  again  emphasize  the  'phrase,  "a  seasoned  tube"  is 
used.  If  the  tube  starts  up  with  the  appearance  of  Fig.  1  or  2,  Plate  V.,  it  is 
of  little  value.  With  Fig.  1,  Plate  V.,  the  reading  will  be  low,  J  to  1  milliam- 
pere :  the  radiographic  value  will  be  fair,  the  penetration  high,  the  definition  good, 
but  the  degree  of  contrast  low.  If  the  tube  gives  the  appearance  which  is  seen 
in  Fig.  3,  Plate  V.,  the  reading  will  be  higher,  the  penetration  good,  the  defini- 
tion excellent,  and  the  contrast  very  high.  We  have  demonstrated  this  many 
times  and  have  adopted  this  means  of  estimation,  confirming  it  always  by  taking  a 
radiograph  of  the  specimen.  (See  Figs.  184  and  185.)  The  tube  is  then  labelled 
with  primary  and  secondary  anmieter  reading  and  length  of  spark  resistance, 
which  resistance  we  do  not  consider  absolute,  as  so  many  conditions  affect  it. 
Figs.  188-191  illustrate  the  value  of  this  method  for  estimatmg  the  radio- 
graphic value  of  x-ray  tubes. 

Development  of  Plates. 

One  of  the  reasons  for  poor  results  is  failure  properly  to  develop  the  plates. 
It  is  not  necessary?  that  the  operator  should  be  an  expert  photographer  in  order 
to  get  good  radiographs,  and  the  practice  of  sending  .r-ray  plates  to  the  pro- 
fessional photographer  to  be  developed  is  to  be  condemned.  The  WTiters' 
experience  has  led  them  to  adopt  certain  routine  methods  of  development 
with  standard  formuko  and  usually  standard  time,  so  that  a  man  of  little  expe- 
rience in  this  line  of  work  can  be  sent  into  the  dark-room  with  a  strong  likeli- 
hood that  he  will  invariably  get  good  results.  The  professional  photographer 
usually  underdevelops  .r-ray  plates,  and  hence  underdevelopment  is  one  of  the 


620 


AMERICAN  PRACTICE  OF  SURGERY. 


-To  illustrate  undeveloped  plate  (only  6  minutes).      Compare  with  Fig.  193,  wliich  ' 
developed  6  minutes  longer.      (Original.) 


Fig.   193. — Taken  under  exactly  same  conditions  as  Fig.  192.  but  development  was  carried  much 
further.     Developed  12  minutes.      (Origmal.) 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


621 


the  great  causes,  of  poor  plates  (Figs.  185-192).  It  is  of  advantage  to  know 
the  principles  of  photography,  to  know  that  the-plate  is  coated  with  gelatin,  that 
the  agent  acted  upon  by  the  light  or  .r-ray  is  principally  silver  bromide,  and 
that  the  richer  the  plate  is  in  this  silver  salt  the  better  the  plate  will  be,  other 
things  being  equal.  For  this  reason,  although  ordinary  photographic  plates 
may  be  good  enough  for  fractures  and  gross  lesions,  for  the  finer  work  they 
are  not  to  be  compared  with  the  special  .r-ray  plates  (see  illustrations  Figs. 
194  and  195). 

Description  of  Dark-room. 

A  well -ventilated  room  from  which  all  white  light  can  be  excluded  is  neces- 
sary. A  single  ray  of  white  light  may  be  responsible  for  poor  results  by  acting 
on  the  photographic  plate  during  the  process  of  development.     After  a  room 


Fig.  194. — Ordinary  Photographic  Plate.    Observe  difference  between  this  and  Fig.  195.    (Original.) 
Fig.   19.5. — Same  subject  as  Fig.  194,  taken  and  developed  under  exactly  same  conditions,  but  on 
a  special  x-ray  plate.     (Original.) 

which  can  be  darkened  completely  has  been  obtained,  the  next  thing  of  impor- 
tance is  to  secure  a  suitable  light  by  which  to  develop  (Fig.  196).  The  light 
advised  by  the  makers  of  x-ray  plates  is  a  ruby  lantern  or  box  through  which 
the  light  is  transmitted  by  means  of  two  layers  of  yellow  fabric  and  one  layer 
of  ruby  fabric  such  as  may  be  obtained  from  any  photographic-supply  store. 
The  light  to  be  used  in  these  lanterns  may  be  a  1 6-candle-power  incandescent 
light,  gas,  a  kerosene  lamp,  or  even  a  candle:  a  candle,  however,  gives  such  a 
dim  light  that  only  one  sheet  of  yellow  fabric  is  necessary.     At  the  same  time 


622 


AMERICAN   PRACTICE  OF  SURGERY. 


it  is  not  safe  to  expose  photographic  plates  even  to  this  hght  for  a  very  long 
time.  This  is  especially  true  as  regards  ortho-chromatic  and  x-ray  plates. 
Some  form  of  tray  in  which  plates  may  be  placed  is  now  necessary.  An 
apparatus  has  been  devised  which  consists  of  two  or  three  shelves,  each  shelf 
capable  of  holding  a  tray.  These  shelves  are  placed  on  a  base  enclosed  in  a 
cabinet  from  which  all  light  may  be  excluded  by  means  of  a  light-tight  door. 
This  base,  by  means  of  transmission  shafts  and  excentric  cams,  is  given  a  rotary 


Fig.  196. — Dr.  Calchvell'.?  Dark-Room  Ruby  Lamp,  with  Bracket  attached. 


rocking  motion  when  connected  with  a  small  electric  or  other  motor.  By 
this  means  the  trays  are  kept  in  motion,  not  simply  from  side  to  side,  but  also 
in  a  rotary  manner;   in  this  way  more  even  development  is  assured. 

The  following  formukp,  which  have  been  used  for  several  years  with  very 
satisfactory  results,  may  be  confidently  recommended : 

Solution  1.  Solution  2. 

Sodium  sulphate  (dried) 4.3'3  grains       Sodium  carbonate  (dried) 735  grains 

Hydrochinon Ill       "  Water 16  ounces 

Glycin .32       " 

Metol 5 

Potassic  bromide 69       " 

Water  (distilled) ad  16  ounces 

Many  other  developers  have  been  tried,  but  they  seem  to  be  less  well  adapted 
to  this  kind  of  work.  It  remains  a  fact,  however,  that  after  an  operator  has 
become  accustomed  to  a  certain  developer  he  can  get  more  satisfactory  results 
with  it  than  with  any  other.  The  developer  recommended  above  will  keep, 
and  may  be  used  over  several  times  if  poured  back  into  the  bottle,  which  should 
be  corked  tightly. 

For  the  development  of  plates  in  which  it  is  desired  to  show  only  the  bone 
structure,  ten  parts  of  solution  No.  1  to  six  of  .solution  No.  2  should  be  taken. 
After  these  solutions   ha^'e  been  mixed,  the  mixture  should  be  poured  into  the 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  623 

tray,  in  which  the  plate  may  then  be  placed.  Great  care  should  be  taken  to 
make  the  developer  flow  evenly  and  completely  over  the  plate;  if  this  be  not 
done  the  plate  will  be  overdeveloped  in  the  parts  that  the  solution  first  acted 


Fig.  197. — Illustrates  underdeveloped  plate  of  renal  calculus.       (The  same  radiograph  as  that  .shown 
on  p.  615).     Negative  so  thin  that  even  under  diffused  light  calculi  cannot  be  seen.     (Original.) 

upon  as  compared  with  the  rest  of  the  plate.  For  this  reason  many  operators 
advise  the  use  of  slow  dilute  developers,  thereby  avoiding  the  tendency  of  the 
image  to  flash  up,  while  the  high  lights  become  overdeveloped  before  the  shadows 


Fig.  19S. — Illustrates  normal  development  of  the  same  subject  as  that  shown  in  Fig.  197.      (Original.) 

can  be  fully  brought  out.     Usually  the  image  will  appear  in  about  fifteen  seconds 
with  this  developer,  and  development  may  be  continued  for  about  six  minutes. 

It  is  advisable  then  to  look  at  the  plate  by  holding  it  up  to  the  ruby  light; 
it  should  be  placed  over  a  sink  so  that  the  developer  will  not  drop  on  the  develop- 
ing bench.     If  the  bones  can  be  seen  distinctly,  showing  quite  light,  develop- 


624  AMERICAN   PRACTICE   OF   SURGERY. 

ment  has  not  been  carried  far  enough  and  should  be  continued  until,  when  the 
plate  is  held  about  six  inches  from  ruby  light,  the  bones  can  hardly  be  seen. 
The  plate  should  next  be  rinsed  in  cold  water.  This  is  important.  It  not  only 
checks  further  development,  but  aids  the  action  of  the  fixing  and  hypo  baths 
in  which  it  must  be  now  placed  before  it  is  exposed  to  white  light.  The  hypo 
bath  is  usually  acid  in  reaction.  The  developer  is  alkaline  in  reaction.  If  we 
put  the  plate  into  this  acid  bath  with  a  quantity  of  alkaline  developer  on  it 
we  soon  neutralize  the  acid  and  precipitate  the  alum,  which  in  many  baths 
is  the  hardening  agent.  The  following  hypo  bath  is  strongly  recommended  by 
the  writers,  it  having  been  given  tests  during  hot  weather  under  extremely 
harsh  conditions: 

Sodium  hyposulphite parts    ii. 

Distilled  water parts   iii. 

Add  to  this  solution: 

Sodium  bisulphite,  in  the  proportion  of grains  100  to  the  O  i. 

After  the  plate  is  fixed — that  is,  when  white  spots  no  longer  appear  when 
the  plate  is  viewed  from  the  reverse  side — it  should  be  allowed  to  remain  in 
the  fixing  solution  for  fifteen  minutes  longer;  this  will  harden  the  film  and 
■clear  the  plate.  It  should  then  be  washed  in  running  water  for  about  twenty 
minutes,  or,  if  running  water  is  not  at  hand,  it  should  be  washed  for  thirty 
minutes  in  four  or  five  changes  of  fresh  water.  The  plate  should  then  be  put 
•on  a  rack  to  dry  where  dust  will  not  be  blown  on  it.  We  strongly  advise  the 
use  of  an  electric  fan  for  drying  plates.  For  developing  plates  of  joints,  the 
chest,  and,  above  all,  for  that  important  part  of  radiograph}^,  the  location  of 
xenal  and  urethral  calculi,  the  following  mixture  is  advised:  8  parts  of  solution 
No.  1,  6  parts  of  solution  No.  2,  and  8  parts  of  cold  water. 

To  properly  develop  plates  of  suspected  calculi  is  by  no  means  easy,  and 
great  attention  should  be  given  to  this  process.  We  believe  that  it  is  possible 
to  detect  calculi  of  very  small  size  even  when  they  are  composed  principally 
of  urates  (pure  uric-acid  stones  being  rare).  (Figs.  197  and  198.)  If  a  dilute  devel- 
oper is  employed  the  process  of  development  requires  a  longer  time,  but  the  con- 
trast between  the  softer  tissues  is  emphasized  and  in  most  cases  the  outline  of  the 
kidney  can  be  made  out.  The  plate  is  allowed  to  develop  for  about  ten  minutes 
before  an  observation  is  made  with  the  ruby  light.  During  this  time  the  rocker  is 
covered  and  the  ruby  light  excluded.  This  precaution  is  advisable  as  plates  may 
be  fogged  by  long  exposure  to  ruby  light.  If  the  plate,  when  held  before  the 
ruby  light,  shows  distinct  outlines  of  the  lumbar  vertebrae,  development  is  allowed 
to  proceed  for  a  few  minutes  longer  or  until  the  vertebra  appear  hardly  dis- 
cernible. The  plate  is  then  fixed,  washed,  and  dried  as  before.  The  temper- 
ature of  the  developer  is  of  great  importance.  If  it  is  too  cold,  that  is,  below 
65°  F.,  development  proceeds  very  slowly ;  if  above  72°  F.  the  plate  is  likely  to  be 
flat  and  devoid  of  contrast,  being  what  is  technically  termed  fogged.  Always  work 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


625 


with  the  developer  at  about  the  same  temperature.  Renew  the  hght  iu  the 
ruby  lantern  when  it  is  below  candle  power;  keep  the  developing  room  clean. 
Use  distilled  or  rain  water,  when  possible,  for  developer  and  use  filters  on  the 
faucets  which  supply  the  water  for  washing  the  plates.  Upright  fixing  baths 
and  washing  boxes  are  advised. 

Method  of  Taking  Plates. 

After  the  tube  has  been  adjusted  the  next  step  of  importance  is  the  proper 
arrangement  of  the  patient;  and  here  success  or  failure  may  occur.  To  ask 
a  patient  to  keep  still  in  an  awkward  or  uncomfortable  position  is  asking  much 
under  the  best  of  circumstances ;    and  when  he  is  actually  under  examination, 


Fig.  199. — Table  for  standardizing  position,  avoiding  tlie  necessity  of  patient  lying  down  for  leg 
and  ankle  negatives  and  conducing  to  muscular  rest  and  therefore  quiet.    (See  also  Figs.  200  and  201.) 

A,  Top  adjustable  by  thumb  screw,  A',  for  upper  arm,  elbow,  forearm,  and  hand. 

B,  Rack  for  plate  in  lateral  views  of  thigh,  knee,  and  ankle.  Clutch  for  holding  plate  seen  directly 
below  letter  B.     Rack  attached  to  D. 

C,  Rest  for  thigh  and  ankle  in  lateral  views  of  thigh,  knee,  and  lower  leg.  Adjustable  at  thumb 
screw  c'.  Fig.  200.  Tube  placed  in  these  views  horizontally  at  same  level  as  part,  while  plate  is  perpen- 
dicularly held  on  rack  B. 

D,  Platform,  adjustable  by  thumb  screw  D',  for  antero-posterior  views  of  thigh,  knee,  lower  leg, 
and  ankle.  Plate  rests  flat  on  platform,  which  is  raised  to  level  of  chair  in  wliich  patient  sits.  Top 
A  is  lifted  out  of  its  sockets,  and  tube  placed  vertically  above  part. 

D  also  is  used  for  lateral  position  of  ankle.  (See  Fig.  201.)  A  small  table  of  thin  wood,  practically 
offering  no  resistance  to  the  ar-rays,  is  placed  under  the  foot  in  the  weight-bearing  position.  The 
plate  is  held  behind  it  by  clutch  on  rack  B,  and  the  tube  placed  horizontally  is  focussed  over  the  malleoli. 

Webbing  straps  and  narrow  sand-bags  will  be  found  useful  in  holding  the  parts  immobile,  and  the 
ease  and  constancy  with  wliich  standard  views  may  be  obtained  are  satisfactory. 

Most  of  the  principles  here  combined  into  one  table  were  devised  as  separate  apparatus  by  Dr.  L. 
A.  Weigel,  of  Rochester,  N.  Y. 
VOL.    I.— 40 


626 


AMERICAN  PRACTICE  OF  SURGERY. 


surrounded  by  more  or  less  apparatus 
it  seems  unreasonable  to  expect  him 
ticularly  women,  object  to  lying  down, 
able  which  may  be  used  when  the  arm, 
this  purpose  the  writers  ha^T  devised 
201.  Having  arranged  the  patient 
now  place  the  plate  beneath  the  part 


the  effect  of  which  is  unknown  to  him, 
to  remain  cjuiet.  Many  patients,  par- 
se that  some  form  of  apparatus  is  advis- 
leg,  or  chest  is  to  be  radiographed.  For 
the  apparatus  illustrated  in  Figs.  199  to 
as  comfortabh-  as  possible  we  must 
to  be  radiographed,  and  adjust  the  tube 


Fig.  200. — Front  View  of  Table  shown  in  Fig.  199. 


at  the  standard  distance  for  that  part  over  the  standard  landmark,  inrmobil- 
izing  the  part  as  completely  as  possible  by  means  of  sand  bags,  straps,  or, 
better  still,  by  means  of  the  method  perfected  by  Dr.  Albers  Schoenberg;  that 
is,  by  means  of  the  compression  cylinder  to  be  described  later.  The  writers 
have  used  for  j^ears  several  sizes  of  sand  bags  varying  in  weight  from  t^vo  to 
twenty  pounds.  These,  if  not  filled  too  hard,  maj^  be  used  to  hold  even  very 
sensitive  parts  almost  perfectly  quiet.  It  should  be  remembered  that  com- 
plete immobilization  is  absolutely  essential  to  good  radiographs.  Simply  ask- 
ing a  patient  to  keep  still  is  not  sufficient.  Immobilize  the  part  in  everj'  case 
no  matter  how  simple. 

We  have  said,  place  the  tube  at  the  standard  distance  for  that  part  over  the 
standard  anatomical  landmark.  We  feel  so  strongly  convinced  that  this  is 
essential  to  the  intelligent  interpretation  of  radiographs  that  the  following 
scheme  has  been  adopted  and  is  in  force  at  the  laboratory  of  the  Massachusetts 
General  Hospital. 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


627 


When  taking  radiographs  involving  joints  the  writers  adjust  the  anode 
immediately  over  the  centre  of  that  particular  joint,  and  take  both  antero- 
posterior and  lateral  views,  great  care  being  exercised  to  secm-e  the  same  posi- 
tion as  that  of  the  standard  radiograph  with  which  it  is  to  be  compared.  We 
fully  realize  that  in  many  cases  it  is  impossible,  owing  to  ankylosis,  deformity, 
or  for  some  other  reason,  so  to  adjust  the  patient  that  this  result  shall  be  attained, 
but,  wherever  it  is  possible  to  do  this,  such  procedure  is  insisted  upon,  and 
the  uniformity  in  radiographs  thus  obtained  warrants  the  extra  time  and  trou- 
ble.    To  convince  one's  self  of  the  need  of  such  attention  to  detail  it  is  only 


Fig.  201.— Table  in  Actual  Use.     (See  Figs.  199  and  200.) 


necessary  to  take  radiographs  of  the  head  of  the  humerus.  For  example,  one 
plate  may  be  taken  with  the  arm  in  outward  rotation,  and  then  a  second  one 
with  the  arm  in  inward  rotation.  A  comparison  of  these  two  radiographs  will 
show  decided  differences.  In  fact,  many  very  different  radiographs  may  be 
obtained  of  the  same  part  by  making  comparatively  slight  .variations  in  the 
position.  For  this  reason  some  standard  position  and  distance- of  the  tube, 
and,  whenever  possible,  standard  position  of  the  part,  are  essential.  If  an 
antero-posterior  view  is  necessary,  let  it  be  such  in  reality,  and  not  a  three- 
quarter  view,  or  one  in  which  the  plate  was  tilted  a  trifle,  thus  rendering  com- 
parison with  the  standard  almost  useless. 

If  the  hip  joint  is  to  be  radiographed,  the  anode  is  focussed  over  the  joint  as 
nearly  as  possible,  the  greater  trochanter  and  the  anterior  superior  spine  being 
used  as  lanchnarks.     The  writers  always  work  with  the  anode  at  least  eighteen 


628 


AilERICAX  PRACTICE  OF  SrRGERY, 


inches  from  the  plate;  if  the  patient  is  a  large,  fat,  or  muscular  individual  the 
distance  ^^■ill  necessarily  be  just  so  much  greater — from  two  to  four  inches  more. 
The  greater  the  distance  the  less  the  distortion. 

^Vhen  taking  radiographs  for  the  localization  of  calculi,  renal  or  ureteral, 
it  is  necessary  to  adopt  the  following  routine  procechu-e.  The  patient's  bowels 
are  completely  evacuated,  by  means  of  Epsom  salts  and  castor  oil,  twenty-four 
hours  before  the  radiograph  is  to  be  taken :  the  patient  is  also  requested  to  eat 
sparingly  and  only  easily  digested  food  during  this  time.     This  is  considered 


Fig.  202. 


Fig.  203. 


Fig.  202  illustrates  the  necesf=it}-  of  liaA-ing  the  tube  in  a  definite  position  Notice  the  difference 
between  tliis  picture  and  Fig.  203.      (Original  ) 

Fig.  203. — Same  .subject  as  Fig.  202.  Position  of  tube  was  changed  and  patient's  arm  rotated. 
(Original.)     Notice  difference  in  width  of  head  of  humerus  as  compared  to  Fig.  202. 


of  such  importance  that  it  should  be  insisted  upon.  "When  the  patient  is  ready 
to  be  radiographed,  he  is  placed  on  the  table,  with  the  shoulders  elevated  and 
the  legs  flexed  (see  Fig.  204).  The  compression  cjdinder  is  then  adjusted,  so  that 
the  upper  border  of  the  cylinder  is  just  le^-el  with  the  seventh  or  the  eighth  costal 
cartilage.  The  cylinder  is  next  pressed  down  firmly,  then  tilted  upward;  b}'  which 
means  the  last  two  ribs  will  be  made  to  appear  on  the  plate,  thus  enabling  the 
operator  to  be. sure  that  the  entire  kidney  is  under  observation.  It  is  always 
advisable  to  take  plates  of  both  kidneys  and  of  the  entire  ureteral  tract.  This 
makes  it  necessary  to  take  several  plates;  but,  as  we  feel  convinced  that  nearly 
all  calculi  may  be  detected  by  means  of  the  .r-ray  (except,  possibly,  uric-acid), 
such  procedure  should  always  be  obser-\'ed  in  cases  of  suspected  calculi.  Great 
care  must  be  observed  in  the  interpretation  of  such  radiographs.  The  illu- 
minating lantern  (Fig.  176)  should  be  used  and  the  plate  carefully  studied.  The 
plate  should  show  the  last  two  ribs,  the  transverse  processes  of  the  lumbar 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


629 


vertebrse,  the  psoas  magnus,  and  the  quadratus  himborum  muscles;  and  in 
patients  of  one  hundred  and  seventy  pounds  or  less  the  outline  of  the  kidney 
should  be  made  out.  Under  such  conditions  we  believe  it  possible  to  detect 
very  small  calculi  even  when  they  are  composed  principally  of  urates. 

It  should  be  remembered  that  sesamoid  bones,  vein  stones,   also  cheesy 


Fig.  204. — Shows  how  ej-liuder  may  be  used  with  ordinary  rattan  couch.  Care  must  be  taken  to 
fasten  the  cyUnder  so  securely  tliat  respiratory  movement  will  not  move  cylinder.  This  is  necessary, 
as  cylinder  and  tube  holder  are  attached  to  the  same  support,  and  consequently  any  movement  of  the 
C3'Under  will  move  the  tube  and  thus  spoil  definition.  (Original.)  Apparatus  adjusted  for  suspected 
renal  calculi. 

deposits  in  the  calyces  of  the  kidneys  have  been  mistaken  for  calculi;  and 
we  believe  also  that  in  one  case  a  foreign  body  in  the  appendix  was  mistaken 
for  a  ureteral  calculus. 


Localization  of  Foreign  Bodies. 

For  the  localization  of  foreign  bodies  the  following  method  may  be  adopted: — 

Whenever  it  is  possible  to  do  so,  the  foreign  body  should  be  located  first 

by  means  of  the  fluoroscope.     The  fluoroscope  used  by  the  writers  is  illustrated 


630 


MIERIC.^N  PRACTICE  OF  SURGERY. 


in  Fig.  183,  A.  A  diaphragm  is  used  in  connection  with  the  tube  so  that  only 
a  limited  field  is  under  observation  at  one  time;  by  this  means  the  fluoroscopic 
localization  is  rendered  much  more  accurate,  as  a  foreign  body,  if  one  should 
be  observed,  must  necessarily  be   confined  to  the  area  of  ilhmiination,  such 


Fig.  205. — Represents  specimen  with  needle  buried  in  it.  Dark  triangular  shadow  near  needle  is  a 
piece  of  lead  used  as  a  mark  (the  same  as  that  used  on  patient's  skin).  Notice  the  two  shadows  of 
the  needle.  Anode  was  16f  inches  from  plate.  Shadows  of  needle  exactly  ^  inch  apart.  Tube  was 
moved  3  inches  to  the  right,  then  3  inches  from  the  left,  of  central  point.  Needle  was  -jj^  of  an  inch 
deep.      (Original.) 


area  being  dependent  upon  the  size  of  the  diaphragm.  (A  one-inch  diaphragm, 
at  a  distance  of  about  twenty-four  inches  from  the  tube,  gives  a  three-inch 
field.)  The  orthodiagraph,  as  devised  by  Dr.  Moritz,  is  highly  recommended 
for  this  purpose.     After  the  foreign  body  has  been  located  in  one  plane  by  means 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


631 


of  the  fluoroscope,  such  location  should  be  marked  on  the  skui  of  the  patient. 

The  plate  is  next  to  be  placed  in  ]3osition.  The  anode  of  the  x-ray  tube  is  then 
focussed  over  the  mark  made  on  the  skin.  The 
distance  of  the  anode  from  the  plate  is  carefully 
measured  and  recorded.  The  ■^Titers  work  with 
the  anode  at  a  distance  of  fourteen  inches  from 
the  plate.  After  the  tube  has  been  accurately 
focussed  over  the  mark  on  the  skin,  which  cor- 
responds to  the  foreign  body,  the  tube  is  to  be 
moved  three  inches  to  the  left  and  an  exposure 
made.  The  tube  is  then  to  be  moved  first  back 
to  the  central  or  starting-point  and  then  after- 
ward three  inches  to  the  right.  Great  care  shoud 
be  used  in  making  the  measm-ements,  and  the  ex- 
posures must  be  made  at  the  same  distance  (four- 
teen inches)  from  the  plate.  The  plate  is  now 
to  be  developed,  and,  unless  the  object  is  lo- 
cated at  a  considerable  depth  from  the  skin, 
two  images  will  appear.  The  distance  between 
the  two  images  is  measured  and  the  depth 
calculated  (see  Figs.  205  and  206). 

Many  operators  use  two  separate  plates  rather 
than  make  two  exposures  on  one  plate.  This 
may  be  necessary  m  some  cases,  but,  as  a  rule, 
one  plate  with  double  exposiu'e  will  do.  The 
writers  always  fasten  a  piece  of  lead  on  the 
patient's  skin  somewhere  near  the  foreign  body. 
This  object  appears  on  the  plate  and  is  a  guide 
to  the  surgeon.  Dr.  MacKenzie  Davidson  has 
devised  a  very  ingenious  method  and  apparatus 
for  the  localization  of  foreign  bodies.' 

For  locating  foreign  boches  in  the  eye  the 
apparatus  and  technique  of  Dr.  Sweet,  of  Phila- 
delphia," may  be  used  to  advantage. 


Fig.  206.— Illustrates  plan  of  cal- 
culation as  to  location  of  foreign 
body. 

Nos.  1  and  2  correspond  to  shadow 
of  needle,  and  are  -j  inch  apart — the 
same  distance  as  the  shadows  on  the 
plate.  Nos.  3  and  4  correspond  to 
the  two  positions  of  the  tube.  No. 
5  corresponds  to  distance  of  anode 
from  plate.  The  i:oint  where  the 
Unes  intersect  represents  depth  of 
body  from  surface  next  to  plate. 
(Original.) 


'  Lancet,  1897,  p.  1001. 

2  Archives  of  Ophthalmology,  1898,  p.  377. 


632 


AAIERICAN  PRACTICE  OF  SURGERY. 


CojiPKESSioN  Apparatus. 

To  omit  to  mention  in  the  description  of  an  x-ray  plant  the  compression 
cj'linder  of  Albers  Schoenberg  would  be  to  omit  one  of  the  essentials  to  good  and 
accm'ate  radiograph}'. 

This  ingenious  device  is  so  thoroughly  descriljed  and  illustrated  in  the  cata- 
logues of  dealers  in  x-ray  apparatus  that  only  the  principles  and  advantages 
need  to  be  spoken  of  here.  At  the  same  time  it  will  not  be  out  of  place  to  give 
here  a  brief  description  of  the  compression  cylinders  which  we  are  in  the  habit 


Fig.  207. — Compression  Diaphragm  of  Albers  Schoenberg.  It  consists  of  an  adjustable  frame  on  a 
■wooden  base,  with  a  detachable  lead-lined  compression  cylinder  (4  inches  in  diameter),  lever  arrange- 
ment, tube-holder,  and  three  lead  diaphragms. 


of  using,  these  cylinders  being  modifications  of  Albers  Schoenberg's  much  more 
elaborate  apparatus.    (Fig.  207.) 

On  a  previous  page  we  have  spoken  of  the  absolute  need  of  immobilization 
of  the  part  to  be  radiographed.  The  compression  cylinder  fm-nishes  the  ideal 
method  of  immobilization.  By  this  means  the  part  may  be  completely  fixed 
and  all  movement  prevented,  thus  obviating  one  of  the  chief  causes  of  poor  plates. 

Secondary  radiations  have  been  spoken  of  as  being  another  cause  of  the  lack 
of  definition,  of  fogged  or  blurred  plates,  .such  radiations  being  given  off  to  some 
extent  by  all  objects  with  which  the  x-ray  comes  in  contact.  By  means  of  the 
compression  cylinder  with  its  diaphragms,  secondary  radiations  are  almost  com- 
pletely eliminated,  only  the  more  direct  rays  being  used.      (Figs.  211  and  212.) 

The  importance  of  focussing  the  anode  over  the  part  to  be  radiographed 
has  been  emphasized.     The  compression  cylinder  enables  the  operator  to  do 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK. 


633. 


this  very  accurately,  as  the  centre  of  the  cylinder  corresponds  to  the  focal  spot 
on  the  anode  of  the  .r-ray  tube.  Its  advantages  are:  uniformity  of  distance 
of  the  anode  from  the  surface  of  the  body,  thus  setting  a  standard  distance; 
greatly  increased  definition  owing  to  elimination  of  secondary  radiations; 
better  immobilization  of  the  part  exposed;  and,  finally,  the  fact  that  in  the 
more  compressible  parts  of  the  bod}',  such  as  the  abdomen,  the  cylinder  enables 
the  operator  to  focus  the  tube  over  the  area  to  be  observed  as  well  as  to  com- 
press the  part  and  thus  reduce  its  thickness  to  a  considerable  degree.     Another 


Fig.  208. — Shows  how  tube-stand  tabic  is  used  when  antero-postcrior  ^'icw  of  knee  is  desired.  Patient 
is  in  chair,  and  leg  is  placed  on  adjustable  table,  as  described  under  compression  C5'linder.  (Original.) 
Tlie  operator  may  be  observed  behind  the  lead  screen  in  which  a  hole  4  inches  in  diameter  is  cut. 
This  hole  is  covered  with  lead  glass  ^  inch  thick. 


advantage,  and  one  that  will  appeal  to  the  operator  who  has  to  use  many  plates, 
is  the  fact  that  with  this  apparatus  only  those  which  measm-e  either  five  by 
seven  or  eight  by  ten  inches  can  be  employed.  The  cheapness  and  efiicienc)'' 
of  the  apparatus  are  features  which  also  commend  it  to  favorable  considera- 
tion. 

It  is  constructed  in  the  following  manner:  A  board  three-fourths  inch  in 
thickness,  fourteen  inches  long,  twelve  inches  wide  is  taken.     In  the  centre  of 


634  a:\iericax  practice  of  surgery. 

thiy  board  a  hole  three  and  tliree-fourths  inches  in  diameter  is  cut,  with  a  groove 
one-fourth  inch  Avide,  three-sixteenths  inch  deep.  Into  this  hole  is  set  the 
diaphragm.  The  diaphragm  consists  of  a  piece  of  lead  three-sixteenths  of 
an  inch  thick,  in  the  centre  of  which  a  circular  hole  one  and  three-fourths  inch 
is  cut.  On  the  bottom  of  the  board  a  sheet  of  lead  three-sixteenths  of  an  inch 
thick  is  fastened  so  that  it  covers  the  board  to  within  one-half  of  an  inch  of 


Fig.  209. — Shows  correct  adjustment  of  tube  to  diaphragm.  Elliptical  shadow  (see  Fig.  210)  is 
caused,  probably,  by  secondary  radiations,  and  indicates  the  value  of  diaphragms  in  radiograpliic 
work.  A  fluoroscope  will  give  almost  equal  illumination  when  held  IS  inches  from  tube,  it  being  thus 
impossible  to  detect  by  this  means  the  secondary  radiations.     (Original.) 

the  edges.  Three  cleats  are  fastened  to  the  lead  and  are  so  arranged  around 
the  circular  apertm-e  that  the  cjdinder,  about  to  be  described,  may  be  slid 
in  or  out,  according  as  the  diaphragm  is  to  be  used  with  c}dinder  or  not.  One 
cleat  is  fastened  near  the  back  of  the  aperture  so  that  the  centre  of  the  cylinder, 
when  pushed  in  against  it,  must  be  exactly  under  the  centre  of  the  diaphragm ; 
the  other  two  cleats  are  fastened  so  as  to  centre  the  cvlinder  in  the  lateral  direc- 


THE  TECHNIQUE  OF  RADIOGRAPHIC  AVORK. 


635 


tion.  The  cylinder  used  by  tlie  writers  consists  of  a  tin  can,  such  as  compressed 
tablets  come  in;  this  is  lined  with  sheet  lead  one-eighth  of  an  mch  thick  and 
soldered  so  as  to  be  securely  held  to  the  sides  of  the  can.  Two  lugs,  or  ears, 
are  now  fastened  to  the  sides  of  the  upper  end  of  the  can,  these  lugs  fitting  into 
the  cleats  on  the  board  as  described.     To  the  top  of  the  board  are  fastened 


Fig.  210. — Shows  how  necessary  it  is  accurately  to  adjust  tlie  tube  to  the  diaphragm;  care  being 
taken  to  place  foca  spot  of  cathode  stream  immediately  over  centre  of  diaphragm.  This  may  be 
easily  accomplished  by  placing  fluorescent  screen  under  cylinder.  If  complete  circle  with  sharp,  well- 
defined  edges  is  seen,  adjustment  is  correct;  if  illumination  is  elUptical,  as  in  this  figure,  the  tube  must 
be  moved  either  to  the  right  or  to  the  left.  (Original.)  Notice  dark  sliadow  inside  lower  part  of  cir- 
cle, obscuring  part  of  ulna  and  radius.      Compare  with  Fig.  209. 


two  uprights  for  supporting  the  .r-ray  tube ;  these  uprights  are  five  inches  high, 
the  ends  of  the  uprights  being  grooved  to  recei^'e  the  x-raj  tube. 

This  cylinder,  with  board  and  tube  holder,  is  now  fastened  to  a  very  rigid 
upright  in  such  a  way  that  it  can  be  raised  or  lowered  at  any  angle  in  the  same 
manner  that  the  ordinary  tube  stand  allows  adjustment  of  the  x-ray  tube.  Ab- 
solute rigidity  of  the  upright  is  essential,  as,  when  a  radiograph  of  the  lumbar 


636  AMERICAN  PRACTICE  OF  SURGERY. 

spine,  for  instance,  is  to  be  taken,  the  cj'linder  is  pressed  down  as  much  as  the 
patient  can  stand,  then  fastened  in  front  by  means  of  a  strap  passing  through 
the  board  to  the  couch  (see  Fig.  204).  If  the  upright  is  not  stiff,  or  if  there  is  any 
play  in  the  board  arm,  respiratory  movement  will  move  the  apparatus  which, 
moving  the  tube,  will  spoil  the  definition  and  thus  defeat  the  chief  aim  of  the 
compression  cylinder. 

Figs.  204  and  207  illustrate  this  apparatus,  with  adjustable  table  on  the  same 
upright. 

The  writers  consider  the  compression  cylinder  essential  to  good  radiographic 
work.  The  apparatus  described  has  the  advantages  of  being  easily  and 
quickly  adjusted  and  purchasable  at  a  reasonably  low  price.  The  cylinder 
being  movable  enables  the  operator  to  use  the  board  alone  when  larger  areas 
than  that  allowed  by  the  cylinder  are  to  be  exposed.  In  such  cases  straps  and 
sand  bags  are  used  when  possible  to  inunobilize  the  parts. 

Stereoscopic   Radiographs. 

The  use  of  the  stereoscope  is  of  undoubted  value  in  the  study  of  the  position 
of  bone  fragments  and  foreign  bodies.  It  necessitates  some  form  of  stereoscope, 
and  the  taking  of  two  negatives  under  exactly  the  same  conditions  as  regards 
time  of  exposure  and  mode  of  development,  and  with  the  tube  at  the  same  ver- 
tical distance  from  the  plate  in  each  case.  After  centring  the  tube  over  the  point 
chosen  as  the  most  desired  area  to  be  viewed,  the  tube,  by  means  of  a  scale  on 
the  tube  stand  or  floor,  should  be  moved  horizontally  one-half  inch  to  the  right 
and  a  negative  taken.  This  plate  should  then  be  removed  and  a  second  one 
substituted,  with  no  change  in  the  position  of  the  part.  The  tube  should  next 
be  moved  three-fourths  inch  to  the  left  or  one-half  inch  to  the  left  of  the  orig- 
inal central  point,  and  the  second  negative  should  then  be  taken  under  the 
same  conditions  as  regards  distance  and  light  overhead.  Thus  we  shall  obtain 
two  negatives  which  give  us  views  of  the  area  desired  from  two  different  posi- 
tions corresponding  roughly  to  the  human  pupils.  It  remains  for  the  stereo- 
scope to  construct  the  images  in  three  dimensions. 

Harjiful  Effects  of  the  A'-Ray. 

Nearly  all  the  measures  used  for  the  relief  of  suffering  are  capable,  when 
used  ignorantly  or  carelessly,  of  producing  in  time  untoward  effects.  The 
a;-ray  is  no  exception  to  this  axiom,  and  the  lesions  which  follow  its  use  are 
among  the  most  insidious  and  the  most  disastrous.  Oiu-  present  knowledge 
of  these  matters  is  most  incomplete.  Enough,  however,  has  been  already 
proved  to  warrant  very  definite  statements,  and  the  evidence  as  to  other  pos- 
sible harmful  effects  is  sufficiently  conclusive  to  demand  the  adoption  of  pro- 
tective measures  which  at  first  sight  may  seem  unnecessarily  strenuous. 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  637 

It  was  early  recognized  that  the  .r-ray  exerted  a  very  definite  effect  upon 
diseased  tissue,  and  that  long  or  repeated  exposures  occasionally  produced  a 
reddening  of  the  skin  or  even  a  deep  slough,  the  onset  of  which  was  slow  and  the 
result  of  which  was  a  tissue  necrosis  most  obstinate  in  healing.  This  gradual 
appearance  of  the  lesion  many  days  after  the  patient's  exposure,  and  the  dis- 
covery made  by  many  operators  that  the  frequent  short  exposures  to  which 
they  were  constantly  subjected  were  causing  lesions  on  their  own  persons,  de- 
monstrated the  subtle  cumulative  effect  of  this  new  and  mysterious  ray. 

The  difficulty  of  determining  the  danger  point  of  these  exposures  is  very 
great,  for  there  are  usually  scarcely  any  subjective  symptoms  at  the  time  when 
the  patient  is  exposed  to  the  ray.  The  mart3Tdom  of  those  men  who  began 
their  x-ray  investigations  soon  after  its  discovery  has  been  a  very  real  one. 
The  lesions  which  have  resulted  have  been  in  many  cases  ineffaceable  and 
have  entailed  an  immense  amount  of  physical  and  mental  suffering. 

The  danger  is  a  positive  one,  and  we  are  doing  our  duty  neither  to  ourselves 
nor  to  our  patients  if  we  do  not  adopt  measures  which  are  known  to  be  ade- 
quately protective. 

The  x-rays  derived  from  a  static  machine  are  somewhat  less  likely  to  produce 
untoward  effects  than  those  from  the  more  powerfvil  currents  of  the  modern 
coil.  But  even  the  static  rays  are  by  no  means  innocuous.  The  experience 
of  some  of  the  most  brilliant  operators  has  shown  that  extremely  painful  lesions 
may  be  produced  by  this  form  of  current,  and  a  malignant  growth  may  ensue 
in  the  ulcerations. 

Sterility.— The  investigations  of  Dr.  F.  Tilden  Brown,  of  New  York,  and 
others  have  seemed  to  show  conclusively  that  long-continued  exposure  to  the 
rays  may  produce  at  least  a  temporary  sterility.  In  some  cases  the  sperma- 
tozoa are  rendered  non-viable,  and  in  others  they  entirely  disappear  from  the 
semen. 

Whether  a  sterility  thus  produced  is  ever  permanent,  provided  further 
exposure  ceases,  is  still  in  doubt.  Such  a  permanent  change  in  the  glandular 
structures  seems  possible. 

The  striking  absence  of  children  in  the  families  of  .r-ray  workers  who  have 
been  constantly  exposed  to  the  rays  without  adequate  protection  is  noteworthy. 
The  cumulative  effect  is  here  apparently  very  important. 

Before  this  subject  was  much  discussed  Dr.  W.  L.  Rollins,  of  Boston,  called 
attention  to  the  fact  that  the  Roentgen  rays  have  the  power  to  cause  abortion 
in  guinea  pigs.  These  experiments  are  suggestive  of  the  necessity  of  exercising 
caution  in  exposing  pregnant  patients. 

It  is  probable  that  the  female  organs  of  generation  are  affected  in  very 
much  the  same  manner  as  are  tlie  male  when  exposed  to  the  effects  of  the  x-ray. 
Cases  can  be  multiplied  in  which  highh^  penetrating  rays  have  been  adminis- 
tered   for    comparatively  long   periods  of   time   in   the   neighborhood  of   the 


638  AMERICAN   PRACTICE   OF   SURGERY. 

genitalia,  and  yet  subsequently  the  patients  have  become  mothers  or  fathers 
of  healthy  children.  It  seems  reasonable,  therefore,  to  conclude  that  single 
exposures  of  short  duration  do  not  as  a  rule  produce  permanent  sterility  in 
either  sex. 

Burns. — A'-raj-  burns,  so  called,  are  of  different  degrees,  from  a  simple  ery- 
thema to  a  definite  tissue  necrosis  which  ma}'  invoh-e  the  layers  beneath  the  true 
skin.  There  is  an  individual  idiosyncrasy  in  the  matter  of  susceptibility,  just 
as  there  is  a  great  difference  in  the  effects  of  sunlight  on  the  skins  of  different 
persons. 

There  may  be  considerable  delay  in  the  onset  of  symptoms.  The  reported 
intervals  of  five  and  six  months  seem  hardly  conceivable,  and  yet  the  writer  has 
on  his  wrist  a  t3^pical  scar  from  an  x-ray  burn  of  the  first  degree  which  did  not 
appear  until  after  the  lapse  of  o^'er  six  months  from  the  time  of  exposure.  It 
should  be  stated,  furthermore,  that  the  wrist  had  been,  as  was  supposed,  ade- 
quately protected,  and  that  no  stage  of  erythema  had  been  observed.  The 
changes  in  the  subcutaneous  vessels,  with  the  resulting  irregular  red  mottling 
of  the  skin,  has  persisted  now  for  about  two  years. 

Depilation  may  occur,  after  prolonged  exposures,  without  definite  burns. 
It  will  perhaps  be  noticed  that  many  x-ray  workers  have  lost  eyebrows  and 
eyelashes.  In  some  cases  also  the  nails  become  brittle  and  ridged.  A  trouble- 
some seborrhoea  is  a  not  uncommon  result,  and  small  keratoses  or  areas  of 
thickened  epithelium,  which  present  the  appearance  of  small  non-sensitive 
calluses,  are  often  seen,  especially  on  the  hands. 

Few  lesions  are  so  persistentl}^  painful  or  so  slow  in  healing  as  the  deep  x-ray 
burns.  Paradoxical  as  it  seems,  areas  of  malignant  disease  often  occur  in  these 
sluggish  granulations,  and  that,  too,  notwithstanding  the  fact  that  the  original 
lesion,  in  these  cases,  owes  its  origin  to  the  agent  so  much  exploited  in  the  cure 
of  mahgnant  growtlis. 

Pathology  of  x-Ray  Burns. — Vose  and  Howe  have  made  careful  studies  in 
the  effects  of  the  Roentgen  ray  upon  cancer  {Journal  of  Medical  Research,  vol. 
xiii..  No.  2).  Their  conclusions,  from  a  study  of  the  literature  and  from  their 
own  microscopic  examination  of  tissues  removed  from  these  burned  areas,  are 
as  follows :  "  Sections  from  the  tissues  of  such  burns  studied  by  us  show  progres- 
sive changes  from  the  surface  downward,  the  more  highl}'  organized  parts  natu- 
rally showing  the  most  marked  changes  or  suffering  most.  The  hair  follicle 
and  the  glands  are  destroyed.  The  prickle-cell  layer  is  increased.  The  cells  of 
this  layer  show  granular  degeneration  of  protoplasm  and  proceed  to  necrosis. 
The  blood  cells  show  a  reticular  deposit  of  fibrin  on  their  inner  coats.  No 
change  of  nerves  was  noted.  These  histological  changes  are  all  that  may  be 
positively  claimed,  since  the  sections  of  .r-ray  ulcers  show  a  purely  necrotic  proc- 
ess— increase  of  elastic  tissue,  increase  of  connective  tissue,  and  colloid  replace- 
ment." 


THE  TECHNIQUE  OF  RADIOGRAPHIC  WORK.  639 


Protective  Measures. 

In  the  light  of  these  facts  efficient  protection  of  both  the  patient  and  the 
operator  has  become  a  matter  not  only  of  wisdom,  but  also  of  imperative  duty. 
Theoretically,  as  Dr.  W.  L.  Rollins  early  pointed  out,  a  box  of  sufficient  z-ray 
density  to  cut  off  the  probably  harmful  rays  should  completely  surround  the 
active  tube,  the  only  exit  for  the  rays  being  furnished  by  a  small  fenestra  through 
which  the  cone  of  light  is  directed  against  the  desired  part.  Practically,  with 
our  increased  speed  of  radiography  and  the  more  perfect  technique  which  does 
away  with  repeated  trials  for  the  purpose  of  securing  a  good  plate,  we  cannot 
feel  that  the  risk  to  the  patient  from  a  single  exposure  to  a  naked  tube  is  great. 
Additional  knowledge  may  well  change  this  opinion ;  and  in  any  event  the  gener- 
ative organs  should  always  be  protected  by  a  piece  of  sheet  lead. 

As  regards  the  operator  no  safeguards  can  be  too  complete.  The  a--ray 
atmosphere  in  which  he  works  is  in  itself  a  baneful  influence  which  it  is  impos- 
sible accurately  to  estimate. 

Although  in  years  past  we  felt  it  necessary  to  judge  the  actinic  cjuality  of  the 
rays  by  fluoroscopic  inspection,  we  have  entirely  given  up  this  test,  not  only  on 
account  of  its  unreliabilitj^,  but  also  because  of  its  demonstrable  danger.  If  this 
method  is  ever  used  by  the  beginner — and  we  discourage  even  this — the  fluoro- 
scope  should  be  a  protective  one  such  as  has  been  described  elsewhere  in  this 
article.  By  careful  observation  of  the  appearance  of  the  tube,  its  shade  of  color, 
the  amount  of  current  used,  and  especially  by  the  reading  of  the  milliammeter,  we 
believe  that  even  the  beginner  may  learn,  after  a  few  simple  trials  on  test  plates, 
accurately  to  judge  the  quality  of  the  light  without  the  use  of  the  fluoroscope. 
This  inspection  may  be  made  through  a  peep-hole  in  the  protective  screen, 
which  peep-hole  should  be  covered  by  a  thick  layer  of  lead  glass.  For  the 
fluoroscopic  examination  desirable  in  certain  cases  of  foreign  bodies  or  frac- 
tures, and  in  the  case  of  thoracic  or  abdominal  diseases,  the  observer  should 
be  guarded  by  a  lead  screen  or  a  protective  suit  of  the  lead  and  rubber  composi- 
tion now  on  the  market.  Of  the  efficient  protectiveness  of  this  latter  material 
we  are  not  sure. 

In  our  private  office  plant  the  arrangements  are  such  that  the  current  can 
be  turned  on  only  when  the  operator  stands  behind  a  permanently  fixed  screen, 
which  is  composed  of  sheet  lead  one-eighth  of  an  inch  thick  and  is  placed  between 
two  layers  of  plate  glass.  A  peep-hole  one  inch  in  diameter  is  cut  in  the  lead. 
The  screen  is  six  feet  high  and  five  feet  broad,  and  the  lead  is  grounded  by 
means  of  a  wire  attached  to  the  gaspipe.  In  taking  radiographs  the  long  axis 
of  the  tube  is  placed  at  right  angles  to  the  screen,  and  the  negative  or  cathode 
pole  of  the  coil  is  farthest  away  from  the  operator,  so  that  fewer  rays  are  pro- 
jected in  hLs  direction.     The  grounding  of  the  lead  screen,  which  collects  the 


640  AMERICAN   PRACTICE   OF  SURGERY. 

iiigh  induction  waves,  ensures  a  safe  disposition  of  this  possibly  harmful  ele- 
ment.    We  do  not  consider  these  safeguards  as  unnecessarily  extreme. 

We  are  dealing  with  a  force  the  exact  natui-e  of  which  we  do  not  under- 
stand. It  is  more  subtle,  perhaps,  than  any  other  influence  in  the  hands  of 
medical  men,  partly  because  it  is  not  yet  full}-  understood,  and  partly  because 
of  its  insidious  -workings.  The  harm  it  is  capable  of  doing  is  second  only  to 
the  good  its  application  daily  accomplishes,  and  the  efforts  of  those  who  essay 
its  use  should  be  earnestly  directed  toward  making  it  an  umnixed  blessing 
for  both  patient  and  physician. 

Screen  for  Protecting  the  Operator. — The  protection  of  the  operator  from 
the  injurious  effects  of  continued  work  in  x-ray  atmosphere  is  of  the  utmost 
importance,  not  only  because  of  the  liability  to  x-ray  dermatitis,  but  also 
because  of  the  possibility  that  the  .r-rays  may  induce  sterility,  as  sho-mi  by 
Dr.  F.  Tilden  Brown,  of  New  York.  Too  much  emphasis  cannot  be  laid 
on  this  subject,  and  every  means  should  be  taken  to  avoid  exposure.  All 
fluoroscopic  measures  supposed  to  furnish  information  regarding  the  photo- 
graphic -^'alue  of  x-ray  light  should  be  abandoned  and  the  operator  should 
learn  to  judge  the  value  of  the  tube  in  use  from  the  color  of  the  fluorescence, 
from  the  resistance  of  the  parallel  spark  gap,  by  means  of  the  milliammeter 
in  the  secondar}-  circuit,  and  by  testing  the  tubes  radiographically  as  described 
under  .r-ray  tubes.  The  -miters  use,  for  the  operator's  protection,  a  lead  screen 
(Fig.  208),  three-sixteenths  of  an  inch  thick,  in  which  a  window  is  cut.  In  this 
window  is  set  a  piece  of  one-fourth-inch  lead  glass.  The  operator  stands  behind 
this  screen,  which  is  about  six  feet  high  and  four  feet  wide.  Tlirough  the 
window  he  observes  the  tube  and  in  this  manner  is  in  all  jjrobability  kept  from 
harmful  effects.  "\^Tien  it  is  necessary  for  him  to  go  near  the  machine  duiing 
its  operation  he  wears  a  lead  apron,  lead-fiUed  gloves,  both  of  which,  as  well  as 
protective  tube  shields,  are  now  on  the  market.  When  it  is  necessary  to  use  the 
fluoroscope,  as  in  chest  observations  and  in  locating  foreign  bodies,  the  pro- 
tective fluoroscope  is  used  as  described  (Fig.  183,  A).  In  view  of  the  observations 
ii:iade  hv  Dr.  F.  Tilden  Bro^\Ti  on  the  question  of  sterility  it  is  advisable  that 
the  bodies  of  all  patients  be  protected  by  means  of  flexible  lead  screens  or  pro- 
tective tube  shields.  As  the  harmful  effect  of  the  rays  is  probably  dependent 
upon  du-ect  and  comparatively  long  exposures,  we  believe  that  the  patients  run  no 
particular  risk  during  the  radiographic  process.  Nevertheless,  in  view  of  the  lack  of 
evidence  on  this  point,  it  is  advisable  that  the  proper  precautions  should  betaken. 

II.  THE  INTERPRETATION  OF  RADIOGRAPHS. 

In  unskilled  hands  the  therapeutic  use  of  the  x-ray  includes  the  serious 
danger  of  burns.  To  the  practitioner  unfamiliar  with  normal  x-ray  anatomy, 
the  interpretation  of  skiagraphs  offers  the  no  less  serious  danger  of  making  an 
incorrect  diagnosis  and  carrying  out  a  ^•icious  or  useless  treatment. 


THE   INTERPRETATION  OF  RADIOGRAPHS.  641 

There  are  certain  definite  rudimentary  conditions  -n-hich  must  be  complied 
with  if  our  interpretations  are  to  be  of  a  sufficiently  trustworthy  character. 

(1)  It  is  preferable,  whenever  this  can  be  done,  to  examine  the  plate  itself 
rather  than  a  print  taken  from  it. 

(2)  In  examming  a  plate  two  factors  are  of  great  importance — the  manage- 
ment of  the  light,  and  careful  attention  to  the  distance  (from  the  source  of  light) 
at  which  the  plate  is  held.  In  the  first  place,  the  light  should  be  evenly  diffused, 
and  at  the  same  time  it  should  be  shut  off  in  such  a  manner  that  it  shall  illu- 
minate only  the  negative. 

The  matter  of  proper  lighting,  especially  to  one  somewhat  unfamiliar  with 
the  examination  of  negatives,  is  of  sufficient  importance  to  warrant  the  descrip- 
tion of  a  practical  illuminator  (see  Fig.  176). 

An  open  square  box,  the  sides  of  which  measure  foiu-  or  five  inches  more 
than  the  edges  of  the  largest  .r-ray  plate  likely  to  be  used,  is  painted  white 
inside,  and  the  antero-posterior  depth  at  the  top  is  made  slightly  less  than  the 
antero-posterior  depth  at  the  bottom,  so  that  a  plate  resting  in  a  frame  applied 
to  the  front  of  the  box  will  be  in  no  danger  of  falling  outward,  and  yet  its  posi- 
tion will  be  nearly  perpendicular.  A  removable  frame  having  an  open  space 
still  slightly  larger  than  the  largest  plate  is  now  fitted  to  the  open  box  and 
held  in  place  perhaps  by  hinges,  hooks  and  eyes.  On  the  inner  side  of  this  frame, 
above,  below,  and  laterally,  are  fastened  one  or  more  candle-shaped  incan- 
descent bulbs  lying  flat  along  the  side  and  having  individual  turn-off  buttons, 
but  wired  to  a  common  plug  on  the  outside  of  the  box.  To  the  outside  of  this 
frame  is  fastened  a  revolving  circle  having  a  rabbeted  opening  of  the  exact  di- 
mensions of  the  largest  plate  to  be  used.  Other  rabbeted  frames  or  kits,  down 
to  the  size  of  the  smallest  plate,  are  now  fitted  accurately  into  this  and  into 
each  other,  and  the  illuminator  is  then  ready  for  use.  The  bulbs  throw  their 
light  against  the  white  back  and  sides  of  the  box  and,  as  a  result,  an  almost 
perfectly  diffused  illumination,  which  can  be  regulated  in  intensity  by  turning 
off  some  of  the  incandescent  lights,  or  by  means  of  a  small  rheostat  on  the 
outside  of  the  box,  is  refiected  through  the  opening.  The  advantage  of  the 
revolving  circle  is  at  once  evident  when  it  is  considered  that  the  standard  sizes 
of  plates  are  all  longer  in  one  diameter  than  in  another.  Thus,  for  example, 
a  pelvis  on  a  large  plate  is  best  viewed  as  if  the  patient  were  standing,  and 
hence  it  is  desirable  that  the  longer  of  the  two  diameters  of  the  plate  should  be 
the  horizontal  one ;  while  in  the  case  of  a  thigh  the  vertical  diameter  of  the  plate 
should  be  the  longer  one.  The  revolving  circle  obviates  the  necessity  of  con- 
stantly changing  en  masse  the  position  of  a  rather  bulky  piece  of  apparatus. 
With  the  intensity  of  this  evenly  diffused  light  regulated  according  to  the  den- 
sity of  the  negative,  the  best  effect,  except  for  the  finest  detail,  is  gained  by 
studying  the  negatives  at  some  distance  from  the  illuminator.  The  less  evident 
lesions  and  differences  of  shadow  are  thus  much  easier  to  appreciate.    A  method 

VOL.  I. — 41 


642  AMERICAN  PRACTICE  OF  SURGERY. 

warmly  recommended  by  one  of  the  best  foreign  interpreters  is  tlrat  of  observ- 
ing a  negative,  thus  evenly  illuminated,  through  a  pair  of  opera  glasses. 

A  good  negative  is  something  absolutely  indispensable.  By  this  is  meant  a 
negative  in  which  soft-part  details  are  not  obliterated  and  in  which  fine  bone 
structure  is  shown.  It  is  possible  by  a  proper  choice  of  the  quality  of  the  light 
so  to  control  the  time  of  exposure  and  method  of  development  that  soft-part 
lesions  will  be  most  faA^orably  shown;  while  with  more  penetrating  ra^'S,  longer 
exposures,  and  with  the  development  carried  further,  the  bone  structure  may 
be  emphasized.  In  the  thinner  parts  a  combination  of  both  can  usually  be 
obtained. 

Data  of  Position. — We  have  alluded  above  to  the  importance  of  standard- 
izing our  positions,  and  in  the  accurate  interpretation  of  negatives  this  is  of 
great  moment.  Before  attempting  to  form  any  judgment  we  must  at  least 
have  the  data  of  position  clearly  in  our  mind.  To  appreciate  possible  dis- 
tortion one  has  simply  to  place  his  arm  between  a  fluoroscope  and  an  active 
tube  and  then  to  move  the  fluoroscope  and  arm  laterally.  The  amount  of  dis- 
tortion thus  to  be  observed  is  surprising. 

Comparison  with  the  Normal. — In  the  medical  school  the  student  has  a  long 
and  thorough  training  in  normal  histology  before  he  is  shown  pathological 
tissue.  He  must  dissect  normal  sulsjects  before  he  can  be  expected  to  recog- 
nize the  gross  lesions. 

In  skiagraph}'  we  are  dealing  with  shadows  of  structures,  not  with  the  visual 
and  tactile  examination  of  these  subjects. 

X-ray  anatomy  differs  materially  from  that  of  the  dissecting-room.  We 
must  learn  to  know  the  internal  structure  of  the  bones  and  must  realize  that  we 
are  looking  through  bodies  of  three  dimensions  and  not  at  a  single  plane  surface. 

The  bony  structures  of  children  at  different  ages  differ  very  much  from 
each  other  and  from  those  of  adult  life.  Yet  the  adult  structures  are  the  only 
ones  in  which  we  receive  our  anatomical  training,  while  the  bone  lesions  of 
children  are  more  common  and  of  greater  import  than  those  of  adult  life. 

The  ununited  bone  centres  of  the  epiphyses  have  not  seldom  been  spoken 
of  as  fractures,  and  the  normal  exostoses  and  bone  ridges  at  the  points  of 
attachments  of  ligaments  and  muscles  have  been  declared  to  be  pathologic. 

It  must  not  be  forgotten  that  sesamoid  bones  often  develop  in  other  ten- 
dons than  the  flexor  longus  hallucis  and  are  usually  of  no  significance  to  the 
po.ssessor. 

It  is  of  importance,  therefore,  that  we  should  become  familiar  with  normal 
skiagraphs  of  all  ages  and  compare  either  mentally  or  actually  the  radiograph 
supposed  to  be  pathologic  with  a  normal  one  of  approximately  the  same  age. 
Thus  only  can  we  progress  in  our  power  safely  to  use  the  Roentgen  rays  as  an 
accurate  method  of  diagnosis. 

In  the  majority  of  cases  the  lesions  are  unilateral,  and  we  have  the  other 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


643 


side  for  our  most  perfect  normal  standard.  Where  it  is  not  practicable  to 
view  both  sides  on  the  same  plate  at  the  same  time,  symmetrical  positions 
should  be  separately  taken.  One  acts  as  a  check  upon  the  other,  and  individual 
idiosyncrasy  does  not  stand  for  the  suspected  lesion. 

Fractures. 

The  diagnosis  of  fracture  is  usually  the  easiest  of  x-ray  interpretations. 
It  is  extremely  hard,  however,  accurately  to  determine,  from  an  x-ray  plate, 
how  outwardly  deforming  even  a  marked  solution  of  continuity  may  be,  or  to 


-Subperiosteal    Fracture    of    Radius.      Faint    line   of   solution    of    continmty   discernible. 
(Or  ginal.) 


predict  how  much  disturbance  of  function  the  lesion  is  likely  to  cause.  The 
necessity  of  having  clear  plates  that  show  the  bone  structure  well,  is  emphasized 
in  the  common  subperiosteal  solutions  of  continuity,  in  which  the  outline  of  the 
bone  shows  no  irregularity  (Fig.  211). 

In  all  but  the  subperiosteal  fractures  it  is  advisable  to  take  at  least  two 


644  AMERICAN  PRACTICE  OF  SURGERY. 

views  of  the  injury;    and  careful  data  relating  to  position  must  be  at  hand 
if  we  are  to  interpret  the  plate  correctly  (Figs.  212  and  213). 

From  a  medico-legal  point  of  view  the  x-ray  evidence  of  the  presence  of  a 
fractiue  must  needs  be  conclusive,  but  any  inference  as  to  the  future  disturbance 
of  function  that  is  likely  to  result  from  a  seeming  malposition  should  be  drawn 
with  the  greatest  caution;  indeed,  such  inferences  should  not,  in  om-  opinion, 
be  offered  or  accepted  in  court  except  in  the  rarest  instances.     Distortion  may 


Fig.  212.  Fig.  213. 

Figs.  212  .\xd  213. — Fracture  of  .\nkle,  showing  the  Neccessity  of  Obtaining  at  least  Two  Views. 
Fig.  212,  which  represents  a  lateral  view  of  the  ankle,  shows  practically  no  deformity ;  wliile  the  antero- 
posterior view  (Fig.  213)  reveals  much  displacement.     (Original.) 

immensely  exaggerate  the  deformity,  and  natm-e  often  restores  perfect  func- 
tion to  imperfectly  apposed  fragments. 

Tuberculosis. 
This  represents,  perhaps,  the  most  common  bone  disease.  It  is  thought 
by  many  of  our  best  pathologists  to  be  ah\-ays  primary  in  the  bone.  If  this 
is  so,  the  .r-rays  repeatedly  fail  to  demonstrate  these  early  foci.  It  is  not 
vnasual  in  the  radiograph  to  find  a  distinct  focus  in  the  bone,  but  it  is  more 
usual  to  discover  first  the  thickened  capsule,  later  the  erosion  of  the  articular 
surfaces,  and  finally  the  real  destruction  of  bone. 


THE  INTERPRETATION  OF  RADIOGRAPHS.  645 

The  focus  of  disease,  when  found,  usually  gives  little  evidence,  from  the 
x-ray  point  of  view,  of  any  inflammatory  bone  process  about  it,  and  appears 
often  as  a  thin- walled  cavity  containing  more  or  less  calcified  matter  (Fig.  214). 

There  are  other  strong  evidences  of  tuberculosis  Avhere  these  more  strikmg 
conditions  are  absent.  Even  before  we  can  demonstrate  the  atrophy  of  the 
soft  parts,  which  is  so  constant  an  accompaniment  clinically,  we  are  able,  in 


Fig.  214. — Tuberculosis  of  last  Sacral  Vertebra.     Irregular  thin-walled  cavity  seea  with  bone  destruc- 
tion and  involvement  of  lumbo-sacral  articulation.      (Original.) 

the  negative,  to  discover  atrophy  in  the  bone  in  the  very  early  stages  of  the 
disease,  often  long  before  we  find  any  distinct  focus.  This  is  of  the  greatest 
importance  in  the  cases  of  early  hip  disease ;  and  here  again  we  must  have  the 
unaffected  side  for  comparison,  preferably  taken  on  the  same  plate  and  always 
with  the  Crookes  tube  focussed  over  the  median  line  of  the  bodv. 


646  AMERICAN  PRACTICE  OF  SURGERY. 

The  lessened  shadow  cast  by  the  bone  of  the  affected  side,  owing  to  the 
diminution  in  the  hme  salts  and  the  slightly  smaller  diameter  of  the  shaft, 
should  make  one  very  suspicious  of  tuberculous  disease  (Fig.  215). 

Tuberculosis  in  a  joint  before  the  destructive  stage  ensues  represents  a 
marked  irritation  and,  of  course,  often  stimulates  epiphyseal  growth.  Here 
we  find  the  explanation  of  the  often-noted  fact  that  m  the  early  stages  of  tumor 
albus  and  hip  disease  the  affected  limb  is  actually  longer  than  that  of  the  sound 


Fig.  215. — Tuberculosis  of   Hip  on  tlie  Left  Side.      Invoh-ement  of  acetabulum  and  head  of  femur. 
Atrophy,  especially  of  neck,  but  also  of  shaft  of  bone.      (Original.) 

side.  In  the  negative  we  find,  as  an  aid  in  reaching  a  correct  interpretation, 
the  characteristic  enlargement  and  squaring  of  the  epiphyses  (Figs.  216 
and  217). 

As  the  process  advances  destruction  is  the  most  characteristic  feature. 
The  bone  breaks  down,  small  sequestra  are  formed,  dislocations  occur,  and 
detritus  is  thrown  out,  with  or  without  circumscribed  abscess  formation  (see 
Fig.  218). 

Finally  comes  repair,  with  new  bone  formation  and  ankylosis,  or  else  a 
new  joint  with  more  or  less  motion  and  sometimes  good  functional  adapta- 
bility (Fig.  219). 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


647 


Fig.  216.— Early  Tuberculosis  of  Knee  on  the  Right  Side.  No  bony  focus  seen.  Marked  thicken- 
ing of  capsule.  Atrophy  of  structure  of  shafts.  Characteristic  enlargement  and  squaring  of  epiphyses. 
Compare  with  Fig.  217.      (Original.) 


Fig.  217.— Quiescent  Tuberculosis  of  Knee.  Same  case  as  that  shown  in  Fig.  216,  after  treatment. 
Acute  swelling  has  subsided.  Some  atrophy  of  size  and  structure  of  shafts  on  the  right  side.  Ep- 
iphyses still  squared  and  enlarged.     (Original.) 


648  AMERICAN  PRACTICE  OF  SURGERY. 

In  the  radiographs,  especially  those  of  the  smaller  joints,  the  thinning  of  the 
cortex  of  the  neighboring  bones  gives  them  the  appearance  as  if  their  outlines 
had  been  pencilled  and  a  fine  line  drawn  about  them.  Though  this  occurs 
in  other  conditions  of  atroph}^ — as,  for  example,  in  anterior  poliomyelitis — 


Fig.  218. — Tuberculosis  of  Tarsus.     Destruction   of  scai>lioid.     In^■olvement  of  astragalus  and  cuboid. 
Marked  structural  bone  atrophy.      (Original.) 


Fig.  219.— I'.iid  Result  of  Tuberculosis  of  Hip  on  the  Right  Side.  .A.truphy  of  size  and  structure 
persist.  New  joint  cavity  and  weight-bearing  pillar  formed.  Over  one-lialf  normal  joint  motions. 
(Original.) 

it  is  met  so  constantly  in  tuberculosis,  as  a  result  of  the  atrophy  due  to  the 
disease,  that  it  is  almost  characteristic.  A  form  of  tuberculosis  called  caries 
sicca  has  been  described.  The  x-ray  evidences  of  this  condition  are  deep  grooves 
in  the  bone  at  the  attachment  of  the  capsule  about  the  anatomical  neck.     These 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


649 


grooves  are  formed  from  an  ingrowth  of  tough,  dry  granulation  tissue.     The 
joint  becomes  gradually  obliterated.     We  possess  no  illustrative  plates. 


Fig.  220 — Tuberculous  Dactylitis.  Spin^e  ventosre.  The  pharanges  of  both  index  fingers — the 
proximal  on  the  left,  the  middle  on  the  right — show  cj'st-like  formations  with  irregular  and  few 
trabeculte.      (Original.) 


The  spinffi  ventosse  are  well  illustrated  by  Fig.  220,  which  was  taken  from 
a  case  of  a  tuberculous  nature. 

Osteomyelitis. 

In  contrasting  osteomyelitis  with  tuberculosis  it  may  be  said  that  while 
tuberculosis  most  commonly  affects  articular  surfaces,  osteomyelitis  rarely 
does  so.  It  is  often  found  in  close  proximity  to  joints,  but,  as  a  rule,  there  is 
no  involvement  of  the  articular  surfaces. 

Except  in  the  very  long  standing  cases  in  which  actual  disuse  has  a  chance 
to  play  a  part,  we  rarely  find  in  osteomyelitis  the  bone  atrophy  which  is  so  con- 
stant an  accompaniment  of  tuberculosis  (Figs.  221  and  222). 

There  are  to  be  seen,  especially  in  the  more  chronic  cases,  an  actual  thick- 
ening of  the  bone  cortex  and  a  ring  of  bone  about  the  osteomyelitic  cavity, 
which  is  more  resistant  to  the  passage  of  the  a;-ra}rs  than  the  rest  of  the  shaft. 

The  sequestra  found  are  often  large  and  of  considerable  2:-ray  density. 

The  two  processes  resemble  each  other  in  that  they  are  both  destructive 
at  some  stage,  and  also  in  the  fact  that  at  times  they  exhibit  the  character- 
istics of  an  almost  malignant  process,  showing  a  tendency  to  fresh  outbreaks 
after  very  long  periods  of  apparent  cure. 


650  AMERICAN  PRACTICE   OF  SURGERY. 

In  considering  the  .r-ray  evidences  of  osteomyelitis,  it  is  perhaps  better 
to  describe  types  rather  than  stages,  for  osteom3^ehtis  is  a  disease  of  so  greatly 
varying  an  etiology  that  it  possesses  no  typical  stages. 

(1)  There  is  a  type  of  acute  circumscribed  osteomyelitis  which  it  is  often 
difficult  to  distinguish  chnicalh^  from  tuberculosis.  The  solution  of  the  dif- 
ficulty constitutes  one  of  the  most  satisfactory  .r-ray  diagnoses,  for  in  this  case 


Fig.  221. — Osteomyelitis.      Femoral  neck  on  the  right  side  snows  new  bone  deposit  along  outer  side. 
No  involvement  of  articular  surface.     No  atrophy  of  shaft.      (Original.) 

the  dictvmi  of  the  method  is  almost  absolute  and  the  simplification  of  treat- 
ment in  the  way  of  operative  measures  is  very  great.  The  disease  is  compara- 
tively common. 

In  all  the  cases  of  this  nature  that  we  have  seen,  a  pm-e  cultiu^e  of  either 
the  Staphylococcus  pyogenes  aureus  or  the  Staphylococcus  pyogenes  albus 
has  been  obtained.     The  lesions  which  they  cause  are  the  small  localized  cavities 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


651 


or  bone  fui'uncles.  They  are  often  chronic  in  character,  and  at  times  are  accom- 
panied by  little  external  evidence  of  the  bone  process.  In  the  radiograph  the 
small  single  or  multiple  cavities  are,  as  a  rule,  easily  seen,  but  in  certain  positions 
they  are  obscured  by  an  overlying  cortex.     They  occm-  commonl}'  near  the  joint 


Fig.  222. — End  Result  of  Osteomyelitis  of  Hip  on  the  Left  Side.  No  atrophy  of  size  or  structure. 
No  involvement  of  articular  surfaces.  New  bony  overgrowtli  as  well  as  partial  destruction  of  great 
trochanter.     Compare  with  Fig.  219,      (Original.) 


Fig.  223. — Circumscribed  Osteomyelitic  Bone  Ca\'it}'  in  Lower  End  of  Tibia  and  at  Epiphyseal  Line. 
"Bone Furuncle."   Culture  of  Staphylococcus  pyogenes  aureus.   Compare  with  Fig.  224.    (Original.) 


652 


AMERICAN  PRACTICE  OF  SURGERY. 


or  exen  at  the  epiphyseal  hue,  ami  they  have  thickened  walls  of  distinct  out- 
line (Figs.  223  and  224). 

(2)  A  far  more  serious  condition  is  the  acute  type,  which  is  much  more 


Fig.  224.— Post-operative  Result  One  Year   Later,  in  case  shown   in   Fig.    223.      Cavitj'  space  filled 
with  new  trabeculte.      (Original.) 


Fig.  225.  Fig.  226. 

Fig.  225. — Diffuse  Osteomyelitis  Following  Measles.  Great  destruction  of  bone,  the  entire  shaft 
appearing  sequestrated.     Much  new  bony  overgrowth.      (Original.) 

Fig.  226. — Diffuse  Osteomyelitis  Undergoing  Healing  Process.  Large  sequestrum  forming.  Same 
case  as  Fig.  225  and  Fig.  227.     (Original.) 

diffuse,  often  involving  nearly  the  whole  shaft  of  a  bone,  and  is  at  once  evident 
in  the  radiograph  (Figs.  225,  226,  and  227).  This  is  the  type  to  which  the 
term  acute  infectious  osteomyelitis  is  usually  applied. 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


653 


Pig.  227.— End  Result  of  Osteomyelitis  following  Measles.      Same  case  as    Fig.   225  and  Fig.  226. 

(Original.) 


Tig.  228. — Chronic  Osteomyelitis  of  Upper  Portion  of   Tibia.     Faint    outline    of   ca\dty   containing 
sequestrum  seen.     Great  cortical  thickening  about  cavitj'.     (Original.) 


654 


AMERICAN  PRACTICE  OF  SURGERY. 


(3)  There  are  some  writers  who  claim  that  there  is  a  chronic  circumscribed 
type  of  osteomyehtis — a  form  which  is  at  times  most  obscure.  In  such  cases 
the  x-ray  should  help  greatly  in  the  diagnosis.  The  disease  is  to  be  distinguished 
from  the  first  type  only  by  the  fact  that  the  cavities  are  of  large  size,  that  they 
often  lie  in  very  dense  bone,  and  that  they  are  to  be  seen  only  in  plates  of  great 
clearness  and  which  show  much  bone  detail  (see  Fig.  228).  It  will  be  noticed 
that,  in  the  case  here  illustrated,  the  articular  surfaces  are  free,  but  that  the 
proximity  of  the  joint  has  allowed  the  2;-ray  to  reveal  the  true  nature  of  a 
condition  which  had  been  treated  for  twenty  years  as  rheumatic  pain. 


11 

^^H 

k  1 

:^H 

1 

1 

1' 

"^^^^H 

Fig,  22fi.— Diffusp  Chronic   Osteomj'elitis   of   Humerus.     Involvement  of  joint.      Resemblance  to  a 
malignant  or  specific  process.     Diagnosis  confirmed  by  operation.      (Original.) 


(4)  Chronic  diffuse  osteomyelitis  is  a  type  more  rarely  encountered.  Clin- 
ically the  diagnosis  is  often  difficult  to  establish;  and,  so  far  as  this  may  be 
accomplished  by  the  aid  of  the  .r-ray,  it  is  sometimes  impossible  to  distinguish 
the  disease  from  one  of  a  malignant  nature  (Fig.  229).  There  may,  in  these 
cases,  be  so  much  cortical  thickening  that  all  evidences  of  cavity  formation 
are  completely  obscured.  It  is  here  that,  with  the  radiograph  alone,  the  dif- 
ferentiation from  a  specific  lesion  may  not  be  practicable. 


THE  INTERPRETATION  OF  RADIOGRAPHS.  655 


Chronic  Non-Tuberculous.  Arthritis. 

There  has  been  much  confusion,  among  writers  on  the  subject  of  diseases 
of  the  joints,   as  to  what  terms  should  be  apphed  to  the  different  forms  of 


Fig.  230. — Atropliic  Arthritis.  General  bone  atrophy.  Locahzed  erosions  and  loss  of  substance 
can  be  seen  most  clearly  in  the  carpal  and  radio-carpal  articulations.  Subluxations  of  phalanges. 
(Original.) 


Fig.  2.'?1. — Hypertrophic  Arthritis.      Overgrowths  of  bone  seen  on  anterior  aspect  of  head  of  tibia  and 
superior  border  of  patella. 


656 


AMERICAN  PRACTICE  OF  SURGERY. 


chronic  rheumatic  disease.  Thus,  for  example,  some  authorities  class  them 
together  mider  the  smgle  head  of  arthritis  deformans,  maintaining  that  they 
represent  different  stages  of  one  and  the  same  disease.      In  America,  on  the 


Fig.  232. — Atrophic  Arthritis  of  Knee.  Weak  bone  shadow  as  compared  to  soft  parts.  Normal 
joint  space  absent  because  of  loss  of  cartilage  substance.  Erosions  on  under  surface  of  patella.  (Orig- 
inal.) 


Fig.  233. — Hypertrophic  Arthritis.  Strong  bone  shadow.  Marked  overgrowths  can  be  most  clearly 
seen  on  terminal  and  some  mid-phalangeal  articulations.  Some  joint  surfaces  destroyed  by  overgrowth 
of  bone  and  cartilage.      (Original.) 

other  hand,  there  are  many  who  regard  them  as  more  or  less  separate  and 
independent  diseases.  So  far  as  it  is  possible  to  judge  from  examinations 
made  with  the  aid  of  the  x-ra.y,  the  statement  is  warranted  that  the  so-called 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


657 


Fig.  234 . — Hypertrophic  Arthritis.     Well-marked  overgrowths  seen  on  femoral  condyles  and  on  the 
under  .surface  of  patella.     Thickened  cartilage  in  popliteal  space.      (Original.) 


Fig.  235. — Infectious  Arthritis.     Marked    periarticular    swelling.     General    diffuse    atrophy,    but    no 
erosions  or  definite  impairment  of  joint  surfaces.     No  hypertrophy.      (Original.) 
VOL.  I.— 42 


658 


AMERICAN   PRACTICE   OF  SURGERY. 


atrophic   or  rheumatoid  arthritis  and  the  hj-pertrophic  form  of  the  disease, 
or  osteo-arthritis,  almost  always,  even  in  the  early  stages,  manifest  distinct 


Fig.  236. — Infectious  Arthritis.  Same  ease  as  tliat  sliown  in  Fig.  235,  but  one  j'ear  later.  Periar- 
ticular swelling  has  largely  disappeared.  No  essential  invoh-ement  of  joint  surfaces.  No  hypertrophy. 
Some  general  atrophy  from  lack  of  use.     (Original.) 


Fig.  237. — Infectious  Arthritis.     Complete  fibrous  joint  ankylosis;  neither  atrophy   nor  hypertrophy. 
No  change  in  articular  surfaces.      (Original.) 

and  separate   conditions.      One  represents  atrophy,   the    other   hypertrophy; 
one  a  destruction  of  cartilage  and  a  loss  of  substance,  the  other  thickening  of 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


659 


cartilage,  the  deposition  of  lime  salts,  and  actual  outgrowth  of  new  bone. 
Watched  from  the  onset  of  the  first  symptoms  the  two  diseases  seem  to  differ 
essentially.  One  is  occasionally  superimposed  upon  the  other  just  as  scarlet 
fever  may  be  accompanied  by  diphtheria.  In  these  rather  unusual  cases  the 
patients  themselves  will,  as  a  rule,  recognize  them  as  distinct  processes.  The 
interpretation  of  the  negatives,  in  suspected  or  pronounced  cases  of  these 
diseases,  is  interesting  and  not  difficult  (see  Figs.  230-234). 


-True  Gout, 
fingers. 


Definite  lo&b  of  hubbtance  of  shafts  of  proximal  i3halange.s  of  index  and  little 
Several  joints  involved.     No  tophi  distinguishable.      (Original.) 


Infectious  Arthritis. 


A  large  number  of  joint  lesions,  single  and  multiple,  are  unquestionably 
produced  by  some  toxin  or  are  due  to  a  true  bacterial  infection.  To  these, 
Goldthwait  has  given  the  name  of  "  infectious  arthritis."  It  is  possible  to 
distinguish  these  by  the  x-rays,  as  well  as  clinically.  Indeed,  when  the  clinical 
diagnosis  is  in  doubt,  the  radiograph  often  furnishes  conclusive  evidence.  The 
joint  lesion  in  the  active  stage  represents  neither  essential  atrophy  nor 
hypertrophy  of  bone  structures.      The  capsule  is  thickened  and  infiltrated. 


660  A^IEMCAN  PRACTICE  OF  SURGERY. 

with  or  without  excess  of  fluid  in  the  joint,  but  with  no  erosion  of  joint  sur- 
faces (see  Figs.  235-237). 

The  z-rays  would  suggest  that  the  so-called  Still's  disease  represents  an 
identical  or  certainly  analogous  process. 


Fig.  239. — Hereditary  Sypliilitic  Disease.  Late  manifestations.  Ju.xta-epipliyseal  form.  Ep- 
iphyses little  affected.  Confluent  areas  of  porosity  in  diaphyses  of  both  tibice.  Increase  in  cortical 
bone,  and  areas  of  bone  deposit  beneath  the  periosteum  in  diaphysis  of  femur  on  the  right  side.  (Orig- 
inal.) 

Gout. 

True  gout  seems  to  be  in  a  class  by  itself.  The  tophi  are  scarcel)^  distin- 
guishable in  the  negative,  but  the  loss  of  substance  of  the  shafts  of  the  bones, 
as  well  as  the  involvement  of  the  joint  surfaces,  is,  in  the  advanced  stages, 
characteristic  (Fig.  238). 

In  interpreting  the  plates  of  any  of  these  chronic  articular  diseases,  the 
stage  of  the  process  must  be  considered  if  confusion  is  to  be  avoided.    Thus, 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


661 


Fig.  240. — Hereditary  Syphilitip  Disease.  Diffuse  cortical  tliickening  of  mid-tibial  and  lower  fibular 
shaft.  New  bone  deposit  beneath  the  periosteum  gi\-ing  rise  to  sabre-shaped  bone.  Tendency  along 
tibial  crest  to  the  formation  of  so-called  "bone-blisters."      (Original.) 


Fig  241. — Periostitis  Albumosa.     Rough  irregular  bone  deposit  about  the  end  of  the  radius,  with  areas 
of  rarefaction  in  the  diaphysis.     Elbow  and  ankle  of  same  case  showed  similar  changes.     (Original.) 


662  AMERICAN   PRACTICE   OF  SURGERY. 

an  atrophic  process,  which  has  become  quiescent  in  anj-  joint,  may  malve  feeble 
attempts  at  repair  and  actuall}'  throw  out  new  bone  at  the  points  of  primary 
erosion;  vice  versa,  a  hypertrophic  process,  carried  to  the  point  of  ankylosing 
a  joint,  may  bring  such  pressure  to  bear  on  cartilaginous  surfaces  that  erosions 


Fig.  242. — Hereditary  Syphilitic  Disease.  Probable  bone  gumma  in  late  form  of  the  disease. 
Increase  in  cortical  bone  and  lighter  shadow  of  newly  formed  calcareous  deposit  on  the  left  side. 
Circimiscribed  lesion.     (Original.) 


occur,  and  the  bones,  from  mere  disuse,  show  atrophy.     The  same  holds  true 
of  the  infectious  types. 

Despite  these  facts,  in  the  majoritj'  of  cases  the  .r-raj'  negative  is  of  almost 
conclusive  value  in  differentiating  the  types  and  revealing  the  essential 
nature  of  the  process. 


THE  INTERPRETATION  OF  RADIOGRAPHS.  663 


Syphilitic   Disease. 

The  bone  lesions  which  occur  as  the  result  of  luetic  infection  are  numerous 
and  varied.  We  shall  attempt  to  describe  the  a;-ray  appearances  of  only  the 
common  types. 

We  have  personall}''  seen  few  pathological  appearances  in  the  ;r-ray  plates 
of  bones  taken  in  the  secondary  stage  of  the  disease.     The  hereditary  and  con- 


FiG.  243. — Tertiary   Syphilitic   Disease.     Circumscribed  bone   gumma.     Marked  increase   in   density 
of  cortex;  apparent  invasion  of  tlie  medulla.     (Original.) 


genital  forms  and  the  tertiary  lesions  give  most  striking  pictures  and  offer  a 
large  opportunity  for  diagnosis. 

The  hereditary  forms  are  divided  into  the  early  and  the  late,  the  former  ap- 
pearing soon  after  birth  and  resembling  clinically  rickets.  Pathologically,  the 
condition  is  represented  by  the  presence  of  gelatinous  masses  beneath  the  peri- 


664 


AMERICAN  PRACTICE  OF  SURGERY. 


Fig.  244. — Hereditary  Sj-philitic  Disease.  T},T3ical  diffuse  syphilitic  osteomyelitis,  showing  in  dif- 
ferent regions  a  deposit  of  bone  beneath  the  periosteum,  thickening  of  cortical  bone,  rough  new  over- 
growth, and  bone  necrosis.     (Original.) 


Fig.  245. — Hereditary  Syphilitic  Disease.     Same  case  as  that  shown  in  Fig.  244,  after  anti-syphUitic 
treatment  covering  a  period  of  two  yeirs.      (Original.) 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


665 


osteum  and  at  the  epiph3'seal  line,  with  sometimes  true  fractures  or  separa- 
tions of  the  epiphyses.  Am.ong  the  other  alterations  there  is  said  to  be  a  thick- 
ening of  the  cortex  and  periosteum  with  gelatinous  deposit  between  the  two. 
We  personally  have  never  seen  a  good  x-ray  plate  of  this  condition. 

One  of  the  later  hereditary  forms  of  S3'philis — the  juxta-epiphyseal  lesions — 
deserves  a  special  mention.  In  these  lesions  areas  of  bone  necrosis  accompany 
a  deposit  of  bone  beneath  the  periosteum  and  some  thickening  of  the  cortex. 


-Hereditary  .Sypliilitic  Disease, 
metacarpal  bones. 


New  deposit  of  bone  beneatli  tlie  periosteum  of  one  of  the 
Old  line  of  cortex  seen.      (Original.) 


Were  it  not  for  this  overgrowth  and  for  the  fact  that  the  articular  surfaces 
are  free,  the  condition  might  be  confused  with  a  diffuse  tuberculosis.  (See 
Fig.  239  ) 

Thickening  of  the  cortex  and  the  deposit  of  bone  beneath  the  periosteum  are 
the  most  characteristic  and  common  evidences  in  the  late  hereditary  and  in 
the  tertiary  forms  of  the  disease.  They  give  rise,  for  example,  to  the  sabre- 
shaped  tibiee  seen  clinically  (Fig.  240). 

It  is  by  no  means  rare  to  find  along  the  shaft  of  this  thickened  bone  small 
areas  of  rarefaction  with  a  cap  of  dense  bone  rising  up  over  them.  They  have 
been  well  named  by  Codman  "bone  blisters." 


666 


AilERICAN  PRACTICE  OF  SURGERY. 


Fig.  247. — Charcot's  or  Tabetic  Joint.  Antero-posterior  ^^ew.  Marked  loss  of  substance  of  inner 
femoral  condyle  and  tibial  liead  on  right  side.  Compare  more  or  less  atropWed  bone  with  normal  unaf- 
fected knee  on  the  left  side.      (Orisrinal. ) 


-Charcot's  or  Tabetic  Joint.     Semilateral  view.     Bone  destruction  with  loose  masses  con- 
taining calcareous  matter.     Irregular  articular  surface  of  tibia.     (Original.) 


THE  INTERPRETATION  OF  RADIOGRAPHS.  667 

The  bone  deposit  beneath  the  periosteum,  spoken  of  often  as  periostitis, 
appears  as  a  faint  locahzecl  bulging  along  the  shaft,  not  unlike  early  callus. 

The  only  conditions  likely  to  be  confused  with  these  lesions  are  those  which 
are  observed  in  the  early  stages  of  an  osteomyelitis  proper  or  in  that  form  of  the 
disease  which  is  known  as  periostitis  albumosa  (Fig.  241).  The  latter  condition 
shows  itself  as  an  irregular  deposit  of  calcareous  matter  outside  the  cortex 
in  proximity  to  the  joint.     In  the  single  case  that  has  come  under  our  observa- 


FiG.  249. — Exostosis  Causing  Fracture  of  Fibula.     Osteoma  meduUosum.     (Original.) 

tion  several  bones  were  affected.  The  normal  bone  ridges  at  the  points  of 
insertion  of  muscles  or  where  ligamentous  structures  are  attached  must  not 
be  mistaken  for  this  calcareous  deposit. 

The  occasional  periostitis  that  occurs  after  typhoid  may  resemble  closely 
the  so-called  bone  blisters,  though  without  the  accompanying  cortical  thickening. 
This  cortical  thickening  is  usually  more  marked  along  one  side  of  the  bone,  often 
encroaching  on  the  medullary  cavity.  The  differentiation  from  an  old  osteo- 
myelitis, by  means  of  the  negative  alone,  may  be  difficult,  and  not  a  few  cases 
of  Paget's  disease,  or  of  osteitis  deformans,  have  been  diagnosed  as  of  a  syph- 
ilitic nature  from  the  presence  of  this  cortical  thickening.     Paget's  disease  is 


668 


AMERICAN  PRACTICE  OF  SURGERY. 


rarely  confined  to  one  bone  except  in  the  earliest  stages;  syphilitic  disease 
often  is.  The  areas  of  rarefaction  commonly  observed  in  osteitis  deformans 
are  not  characteristically  seen  in  this  t3q3e  of  specific  lesion. 

The  bone  gmnmata  observed  in  the  tertiary  stage  of  syphilis  are  both  super- 
ficial and  deep,  the  former  occurring  between  the  bone  and  the  periosteum  and 
causing  ulceration  of  the  cortex.  These  gummata  may  occur  side  bj'  side,  or  they 
may  merge  the  one  into  the  other  through  radiating  connecting  bands.    The 


Fig.  250. — Exostosis  of  Femoral  Shaft.     Osteoma  spongiosum. 

(Original.) 


Structure  of  soft  parts  well  shoiATi. 


deep  gummata  may  occiu-  in  any  part  of  the  bone  and  may  lead  to  fracture. 
The  new  bone  thrown  out  on  the  side  of  the  cortex  next  the  lesion  may  be  of 
ivoiy-like  hardness,  casting  a  very  dense  shadow  (Figs.  242  and  243). 

In  diffuse  syphilitic  osteomyelitis  the  bone  may  be  doubled  or  tripled  in 
volume,  with  numerous  osteophytes  (Fig.  244  and  245). 

Chaxcot's  or  tabetic  joints  should  probably  be  looked  upon  as  true  arthrop- 
athies of  perhaps  neuropathic  origin,  rather  than  as  evidences  of  active  specific 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


669 


Fig.   251. — Enchondromata.     Index  finger  of  left  hand  shows  most  marked  overgrowths.      Small 
buds  seen  on  the  proximal  phalanges,  on  the  left  middle  finger,  and  on  the  thumb.     (Original.) 


Fig.  252. — Medullary  Sarcoma  of  the  Tibia,  of  the  Myelogenous  or  Giant-celled  Variety.     Marked 
cystic  formation  in  the  upper  part  of  the  tibia.      (Original.) 


670 


a:\ierican  practice  of  surgery. 


infection.  They  are  most  cliaracteristic  in  the  .r-ra}^  as  well  as  in  their  clinical 
behavior.  The  instabilitj^  of  the  part  and  the  frequent  tremor  which  sets  in 
when  an  attempt  at  fixation  is  made,  render  it  difficult  to  obtain  clear  radio- 
graphs. "\Mien  they  ha^-e  been  successfully  taken  thej-  show  great  disorganiza- 
tion of  the  joint,  with  more  or  less  destruction  of  large  portions  of  the  articular 
and  juxta-articular  bone,  and  the  jaresence,  in  the  joint,  of  apparently  loose 
masses  of  detritus  often  containing  lime  salts. 


Fig.  253. — Osteo-sarcomaandOsteitisDeformans.  Periosteal  sarcoma  cleA-eloping  in  a  very  advanced 
case  of  osteitis  deformans  (well  seen  in  tibia).  Sarcoma  involves  lower  end  of  femur  and  popliteal 
space.      (Original.) 


The  boggy-feeling  joint  often  gives  a  foggj'-looking  radiograph  (Figs.  247  and 
24S). 

Syphilitic  dactylitis  perhaps  deserves  a  separate  heading.  So  far  as  our 
observation  goes,  it  is  not  a  difficult  matter  to  confuse  the  disease  with 
tuberculosis.  The  distinguishing  features  are:  in  syphilis  there  is  less 
atrophy  of  structure  and  the  articular  surfaces  are  less  often  involved.      If 


THE   INTERPRETATION   OF   RADIOGRAPHS.  671 

loss  of  substance  occurs,  the  bone  ulcer  will  present  clear  edges  and  a  pimched- 
out  appearance  (Fig.  246).  A  tuberculous  da<?t}iitis  is  by  far  the  commoner 
form. 

Exostoses  or  Osteomata,  axd  Exchoxdromata. 

These  conditions  need  little  experience  for  their  interpretation,  since  skia- 
o-raphs  taken  in  different  planes  will  usually  definitely  locate  and  determine 
the  size  of  these  bland  overgro^v ths. 


Fig.  254. — Secondary  Epithelioma  of  the  Tibia  and  Tar.sus.     Cancerous  osteomalacia,  showing  great 
destruction  and  atrophy.      (Original.) 


They  are  by  no  means  always  of  the  same  structure,  which  has  given  rise 
to  the  self-explanatory  terms  "osteoma  ebumeum,"  "osteoma  spongiosum," 
and  "osteoma  medullosum"  (Figs.  249  and  250). 


672 


AMERICAN   PRACTICE  OF  SURGERY. 


Fig.  255. — Osteitis  Deformans  or  Paget's  Disease.  Characteristic  clianges  seen  in  the  bones  of  both 
forearms  and  in  the  third  and  fourtli  metacarpals  of  botli  liands.  Bowing  of  bones,  regions  of  greatly 
thickened  cortex,  and  areas  of  rarefaction.      (Original.) 


THE   INTERPRETATION   OF   RADIOGRAPHS.  673 

The  enchondromata,  or  chondral  osteomata,  appear  in  the  neighborhood 
of  the  joints  as  irregular  masses  of  cartilage  containing  calcareous  matter,  or 
as  true  exostoses.  They  are  supposedly  formed  from  bits  of  cartilage  left  l^ehind 
in  irregular  epiphyseal  development.  They  are  usually  multiple  and  arc  found 
in  various  joint  regions  (Fig.  251). 

Bone  Tumors. 

Sarcomata  are  by  far  the  commonest  bone  tumors,  and  the  distinguishing 
characteristic  of  many  of  the  types  can  be  discovered  by  the  a--rays. 


Fig.  256. — Osteomalacia.      Marked  cj',stic  formation   in   radius  witli   great   loss  of  lime  salts.      Acute 
bend  of  both  radius  and  ulna  at  the  wrist.      (Original.) 

The  myelogenous  or  medullary  giant-celled  sarcoma  is  prone  to  develop 
cysts  in  bone,  and  these  cysts  are  often  filled  with  blood  and  comprise  the  so- 
cahed  bone  aneurisms  (Fig.  252). 

The  tumors  of  the  osteoid  or  periosteal  spindle-celled  type  present  them- 
selves in  the  form  of  smooth,  often  dense  swellings  that  spring  from  the  super- 
ficial surface  of  the  bone  and  are  intimately  connected  with  it,  although  not 
infrequently  the  old  cortical  outline  can  still  be  made  out.  Their  radiating 
appearance  is  often  recognizable  (Fig.  253). 

VOL.  I.— 43 


674 


AMERICAN  PRACTICE   OF   SURGERY. 


The  multiple  myelomata,  usually  round-celled,  tend  to  soften  and  disin- 
tegrate the  bone,  which  is  then  apt  to  undergo  pathologic  fracture. 

We  are  unfamiliar  with  the  appearances  of  the  angio-sarcomata. 

Epithelial  neoplasms  are  probably  rarely  if  ever  primary  in  bone,  but  the 
secondary  forms  and  metastatic  growths  cause  most  extensive  bone  destruction 
and  are  well  described  as  "cancerous  osteomalacia"  (Fig.  254). 

Osteitis  Deformans  or  Facet's  Disease. 

Once  familiar  with  the  typical  gross  appearances  of  osteitis  deformans, 
one  can  hardly  mistake  a  well-marked  case  for  any  other  condition.     The  x-ray 


Fig.  257. — Rachitis.     Wide  cloudy  space  between  tl\e  diapliysis  and  tlie  epiphysis.      Small  size  of 
epiphyseal  bone  centre.     Typical  enlargement  of  contour  seen  at  the  epiph3'seal  line.     (Original.) 


plate  is  equally  characteristic  and  often  fm-nishes  the  most  definite  and  con- 
clusive evidence  in  an  unsuspected  case.  It  is  not  difficult  to  mistake  the 
indefinite  symptoms  of  bone  pain  and  slight  thickening  of  an  early  case  for  spe- 
cific disease  or  osteomyelitis.  If  .r-ray  evidence  is  sought,  it  will  usuall}^  be 
found  that  other  bones  of  the  body  show  typical  lesions  often  quite  unsuspected 


THE   IXTERPRETATIOX   OF  RADIOGRAPHS. 


o75 


Fig.  25S. — Severe  Rachitis,     Slight  bowing  of  femur  on  the  left   side.      Markedly  irregular    epiphy- 
seal line.     Gradual  flaring  of  diaphj'ses.     Extreme  coxa  vara.     (Original.) 


676 


AMERICAN  PRACTICE  OF  SURGERY. 


by  the  patient.  Periosteal  and  cortical  thickening  go  hand-in-hand  with  cir- 
cumscribed and  irregular  areas  of  rarefaction.  The  bowing  of  the  bones  al- 
ways sooner  or  later  appears,  and  the  joint  surfaces,  while  often  showing  hyper- 
trophic nodes  or  spurs,  are  not  otherwise  affected.  The  frecjuently  concomitant 
sign  of  arteriosclerosis  reveals,  in  many  cases,  the  calcified  walls  of  the  larger 
vessels  in  exquisite  outline.     (See  Fig.  255.) 

Osteomalacia. 

Cystic  formations  with  medullary  and  cortical  destruction,  acute  bowings 
and  angular  bendings  of  bones  in  osteomalacia  give  us  a  picture  .-which  can 


Fig.    259. — Chondrodystrophia.      Adult  case.      Wide    .sudden    expanding    of    ends   of   bones.     Short 
stubby  shafts.      No  bowing  in  tlie  bones  affected.      (Originah) 

hardly  be  confused  with  other  conditions  in  a  well-marked  case.  The  large 
amount  of  partly  calcified  callus  and  cartilage  at  the  seat  of  spontaneous 
fracture  is  also  characteristic,  and  so  too  is  the  marked  diminution  of  lime 
salts  in  the  bones  affected  (Fig.  256). 

Rachitis  and  Chondrodystrophia  Fcetalis. 

The  only  condition  likely  to  be  confused  with  a  typical  rachitis  is  the  mis- 
named foetal  rickets,  or  the  condition  more  properly  designated  chondrodys- 
trophia fcetalis. 


THE   INTERPRETATION   OF  RADIOGRAPHS.  677 

In  both  diseases  the  diaph3'seal  ends  are  fiaring;  in  rachitis  this  enlargement 
shows  an  easy  curve,  \A-hile  in  chondrodystrophia-  the  expansion  is  of  an  abrupt 
character. 

In  severe  rachitis  there  exists  a  wide  cloudy  space  between  the  epiphysis 
and  the  diaphysis,  and  the  adjoining  surfaces  are  irregular.  The  contour  of  the 
epiphysis  toward  the  joint  is  smooth,  but  the  bony  centre  is  usually  smaller  than 
normal.  The  shafts  are  of  normal  length,  though  apparently  shortened  from 
the  characteristic  bowing.  The  cortical  bone  will  be  found  dense  on  the 
concavity  of  the  curve,  and  sometimes  indefinitely  porous  on  the  convex 
(Figs.  257  and  258). 


Fig.  260. — Adolescent  Rickets.  Coxa  vara.  Well-nourished  boy  of  fifteen  years.  Wide,  irregular 
epiphyseal  line.  Axis  of  neck  of  femur  is  much  more  horizontal  to  the  axis  of  the  shaft  than  is  normal. 
(Original.) 

In  chondrodystrophia  there  exists  a  rather  narrow  but  fairly  regular  line 
between  the  epiphysis  and  the  diaphysis.  The  shafts  are  short,  unbowed,  and 
u.sually  thick,  and  the  resultant  clinical  dwarfing  is  thus  explained  (Fig.  259). 

DOLESCENT   RiCKETS.        CoXA   VaRA. 

Whether  the  above  condition  is  really  a  late  manifestation  of  a  rachitic 
process  or  a  separate  disease,  the  x-ray  findings  are  conclusive  as  to  the  bent 


678  A.MERICAN  PRACTICE  OF  SURGERY. 


Fig.  261. — Osteogenesis  Imi^erfecta.      Periosteal  dysplasia.      Almost  entire  absence  of  cortical  bone. 
Numerous  fractures.      (Original.) 


THE  INTERPRETATION  OF  RADIOGRAPHS. 


679 


Fig.  262. — Acromegaly.  Comparatively  slight  bony  enlargement.  Wide  joint  spaces.  A  few 
small  osteoi^hytes  on  metacarpal  heads.  Great  enlargement  of  soft  parts.  Compare  with  Fig.  263. 
(Original.) 


Fig.  263.— Giantism. 


General  enlargement,  but  no  other  peculiar  characteristics. 
Fig.  262.      (Original.) 


Compare  with 


680  AMERICAN  PRACTICE  OF  SURGERY. 


Fig.  264. — Congenital  Dislocation  of  the  Hip  on  the  Left  Side.     Rudimentary  acetabulum, 
epiphysis  of  the  head  of  the  femur;  atrophy  of  the  shaft.     (Original.) 


THE  INTERPRETATION   OF  RADIOGRAPHS. 


681 


Fig.  265. — Congenital  Malformation  of  tlie  ^'c^teb^^e.  Two  ■wedge-shaped  and  .se^-eral  malformed 
vertebrse.  Marked  lateral  curvature  (torticollis).  Case  was  recommended  for  operation,  the  futility  of 
which  is  shown  by  the  x-ray.     (Original. ) 


-Congenital  Elevation  of  the  Scapulae.     Showing  curvature  of  the  spine,  wedge-shaped 
vertebrEe,  cervical  rib,  and  malformed  scapulce,  both  elevated.      (Original.) 


682  AMERICAN   PRACTICE   OF  SLTRGERY. 


Fig.  267. — True  Bony  Ankylosis  of   Knee  Joint.     Continuous  bone  trabeculte  to  bridge  old  joint 
space.      (Original.) 


Fig.  20S. — Raynaud's    Disease.     Absorption    of   different   amounts    of   the   terminal    phalanges  with- 
out other  c\'ident  cliange  in  bone  structure.      (Original.) 


THE  INTERPRETATIOxN   OF  RADIOGRAPHS.  683 


Fig.  269. — Calcareous  Deposit  in  the  Course  of  an  Acute  Infectious  Process.  Deposition  of  what 
seem  to  be  Hme  salts  abo\e  the  humeral  head.  Joint  lines  clear.  Subsequent  x-ray  picture,  taken  two 
months  later,  shows  entire  disappearance  of  calcareous  matter.      (Original.) 


684 


AMERICAN   PRACTICE  OF  SURGERY. 


Fig.  270. — -Comparative   Bone   Atrophy.      Bones  in   hand  on  the  right  side  cast   less   dense  shadow, 
and  structure  shows  tliinning  of  trabeoidir.      Disuse  from  a  neuritis.      (Original.) 


THE   INTERPRETATION   OF   RADIOGRAPHS.  685 

neck  and  the  frequent  appearance  of  a  solution  of  continuity  between  the  epi- 
physis and  the  sliaft  resembUng  an  intracapsular  fracture.  The  bone  appears 
of  nearly  normal  structure,  with  perhaps  a  slight  diminution  in  the  amount  of 
lime  salts  (Fig.  260). 

Feagilits  Ossium  or  Periosteal  Dysplasia, 
AND  Osteogenesis  Imperfecta. 

These  two  conditions  are  both  characterized  by  insufficiency  of  cortical 
bone  and  numerous  fractures. 

Fragilitas  ossium  occurs  after  birth  and  is  to  be  distinguished  from  other 
causes  of  brittle  bones. 


Fig.  271. — Bone  Atrophy.      Pes   calcaneus  foUoiving  anterior  poliomyelitis.     Considerable    general 
atrophy  of  size  and  some  of  structure.     Leg  imperfectly  used.      (Original.) 

Osteogenesis  imperfecta  is  congenital,  the  epiphyses  appearing  nearly  normal 
while  the  shafts  manifest  periosteal  dysplasia  and  an  almost  entire  absence 
of  cortical  bone,  with  frequent  fractures  or  bendings  (Fig.  261). 

Acromegaly. 

In  this  disease  there  are  enlargements  of  both  the  soft  parts  and  the  bony 
structures;  the  enlargement  of  the  latter,  however,  being  only  slight  in  degree. 
In  addition,  osteophytes  may  appear  in  the  neighborhood  of  joints,  but  the 
articular  surfaces  are,  as  a  rule,  free.  A  striking  feature  is  the  wide  joint  spaces. 
(See  Fig.  262,  and  compare  with  Fig.  263,  the  latter  being  a  case  of  giantism.) 

Osteoarthropathie  Hypertrophiante  Pneumique. 

This  rare  condition  may  be  confused  with  both  syphilitic  disease  and  oste- 
itis deformans.     It  is  said  that  there  may  be  seen  an  outside  less  dense  layer 


686  AMERICAN   PRACTICE   OF  SURGERY. 

of  newly  formed  periosteal  bone  all  along  the  shaft.     This  laj^er  of  bone,  which 
has  a  striated  appearance,  does  not  completely  obscure  the  old  cortical  line. 
The  only  radiograph  at  our  disposal  shows  this  very  imperfectly. 

Elephantiasis  Ossium. 
This  name  has  been  applied  to  an  enlargement  of  bones  produced  by  perios- 


FiG.    272. — Bone   Atrophj'.      Anterior   poliomyelitis.      Bones    on    the   left    side   sliow   considerable 
atrophy  of  size,  but  little  of  structure.      Leg  in  constant  use.      (Original.) 


teal  irritation.     It  occurs  most  markedly  in  cases  in  which  there  has  been  an 
antecedent  sepsis. 

Congenital  Malformations. 

A'-ray  plates  may  satisfactorily  determine  the  bony  depth  of  the  acetabular 
cavity  and  the  contour  of  the  head  of  the  femur  in  cases  of  congenital  dislocation 
of  the  hip,  and  they  readily  differentiate  this  condition  from  an  early  coxa 
vara,  with  which  it  is  easily  confused  (Fig.  264). 


THE   INTERPRETATION   OF   RADIOGRAPHS.  687 

Obscure  cases  of  torticollis  will  not  rarely  be  found  to  have  malformed, 
wedge-shaped  vertebrae  as  their  etiological  basis,  frequently  associated  with 
one  or  more  cervical  ribs  (Fig.  265). 

Congenital  elevation  of  the  scapula  may  also  be  clearly  demonstrated  by 
the  x-ray  plate  (Fig.  266).  The  recent  investigations  made  by  Dr.  Max  Boehm 
seem  to  show  that  many  cases  of  scoliosis  have  congenital  abnormalities  of  the 
vertebrae. 

Ankylosis. 

The  diagnosis  of  bony  ankylosis  should  be  made  from  the  x-ray  plate  with 
very  great  caution,  and  in  our  opinion  only  when  clear  continuous  bone  trabec- 
ulse  can  be  seen  bridging  the  old  joint  space  (Fig.  267).  Overlapping  bone 
edges  and  dense  fibrous  adhesions  may  often  otherwise  deceive. 

Raynaud's  Disease. 

The  absorption  of  the  terminal  phalanges  without  some  evidence  of  a  repair 
process  is  characteristic.  The  remaining  bone  seems  little  altered  in  structure 
(Fig.  268). 

Deposits  of  Calcareous  Matter. 

It  is  desirable  to  mention  here  a  condition  or  a  group  of  conditions  which 
show  in  the  negative  a  definite  shadow  nearly  as  dense  as  that  due  to  bone. 
This  shadow  usually  appears  in  close  proximity  to  the  joints  and  suggests  an 
excessive  hypertrophic  process.  The  mass  which  may  be  seen  in  Fig.  269 
developed  in  the  course  of  an  infectious  arthritis  of  the  shoulder,  and,  under 
antirheumatic  treatment,  it  was  found — two  months  later,  when  a  second 
x-ray  picture  was  taken — to  have  disappeared  entirely.  We  have  noted  almost 
the  same  appearances  in  an  x-ray  picture  of  an  old  wen,  the  residue  of  whose 
contents  was  almost  pure  calcium.  Doubtless  other  conditions  will  be  found 
to  give  similar  shadows. 

Simple   Bone  Atrophy'. 

A  few  words  should  be  said  under  this  heading,  although  many  of  the  con- 
ditions in  which  bone  atrophy  is  an  essential  feature  have  already  been  described. 

The  condition  is  easily  demonstrated  by  the  x-ray  if  we  have  a  normal 
standard  of  comparison,  the  two  pictures  being  taken  preferably  at  the  same 
time  and  on  the  same  plate,  but  in  any  case  under  the  same  conditions  of  expos- 
ure and  development. 

In  tuberculosis  it  is  a  phenomenon  of  almost  constant  occurrence.  In  atro- 
phic arthritis  we  always  expect  to  find  it.     In  certain  neurotrophic  disturb- 


688  -\-MERia\X   PRACTICE   OF   SURGERY. 

ances  and  in  the  reflex  joint  atrophies  it  is  present.  Senile  changes  in  bone 
are  shoviTi  b}'  a  general  thinning  of  the  cortex  and  by  a  diminution  in  the  number 
of  the  trabeculse.  Simple  disuse  apparently  always  decreases  the  quantity  of 
lime  salts,  and  thus  the  more  radiable  bone  casts  a  fainter  shadow  on  the  plate 
(Fig.  270).  Cases  of  anterior  poliomyelitis  show  the  smaller  size  of  the  afl^ected 
bones,  which  are  usually  of  less  densitj^  than  the  normal  (Figs.  271  and  272). 

We  should  be  careful  to  make  a  distinction  between  atrophj^  of  structure  and 
atrophy  of  size.  Both  are  often  found  together,  but  not  rarelj'  one  is  present 
and  the  other  absent. 


PART  IV. 

GENERAL  SURGICAL  TREATMENT. 


GENERAL  PRINCIPLES  OF  SURGICAL  TREATMENT 
AND  THE  VARIOUS  PROCEDURES,   INSTRU- 
MENTS, ETC.,  THAT  FACILITATE  THE 
APPLICATION   OF  THESE 
PRINCIPLES. 

By  JAMES  E.  MOORE,  M.D.,  Minmapolis,  Minnesota. 


In  1579  Ambroise  Pare,  the  greatest  surgeon  of  his  day,  pubhshed  a  volumi- 
nous work  on  chirurgery,  in  which  he  said :  "  For  God  is  my  witness,  and  all 
good  men  know,  that  I  have  laboured  fifty  years  with  all  care  and  pains,  in  the 
illustration  and  amplification  of  chirurgery ;  and  that  I  have  so  certainly  touched 
the  work  whereat  I  aimed,  that  antiquity  may  seem  to  have  nothing  wherein  it 
may  exceed  us  beside  the  glory  of  invention,  nor  posterity  anything  left  but  a 
certain  small  hope  to  add  some  things."  The  progress  of  surgery  was  so  slow  in 
those  days  that  this  work  was  the  standard  for  over  one  hundred  years .  Seventy 
years  after  its  publication  in  Paris  it  was  translated  into  English  and  published 
in  London.  This  same  complacent  spirit  seems  to  have  pervaded  the  profession, 
and  progress  was  correspondingly  slow  up  to  within  the  last  thirty  years ;  since 
which  time  surgery  has  made  more  progress  than  in  all  time  before,  and  sur- 
geons begin  to  feel  that  the  limitations  of  surgery  are  almost  boundless. 

Modern  surgery  had  its  beginning  in  1865,  when  Joseph  Lister,  of  Glasgow, 
Scotland,  published  the  results  of  his  experiments  and  established  the  "Germ 
Theory  of  Disease."  In  1858  Pasteur  announced  to  the  world  that  fermentation 
and  putrefaction  are  due  to  the  action  of  living  micro-organisms,  and  are  there- 
fore living  processes.  Up  to  this  time,  inflammation  and  suppuration  had  been 
considered  necessary  accompaniments  of  a  wound.  Lister  reasoned  that  if 
putrefaction  and  fermentation  were  due  to  the  presence  of  germs  and  could  be 
prevented  by  their  exclusion,  suppuration  and  certain  diseases  must  be  due  to 
their  presence  and  could  be  prevented  by  their  exclusion.  He  demonstrated  by 
experiment  that  a  wound  made  in  a  clean  skin  by  clean  hands  and  instruments 
and  protected  by  clean  dressings  would  heal  without  inflammation  or  suppura- 
tion. The  application  of  this  germ  theory  has  revolutionized  the  practice  of 
medicine  and  surgery,  and  has  added  thousands  of  years  to  human  life.  It  has 
made  possible  the  prevention  and  suppression  of  many  epidemics,  and  has 
changed  hospitals  from  pest-houses  to  houses  of  refuge.  The  discovery  of  the 
tubercle  bacillus  by  Koch,  published  in  1882,  was  one  of  the  many  advances 

691 


692  AMERICAN  PRACTICE  OF  SURGERY. 

made  possible  by  using  the  germ  tlieory  as  a  working  basis.  Up  to  that  time 
the  term  scrofula  was  applied  to  swollen  lymph  nodes,  chronically  inflamed 
joints,  and  other  conditions  now  known  to  be  due  to  the  presence  of  the  tubercle 
bacillus,  and  the  condition  was  believed  to  be  hereditary.  Lister's  theory  was 
not  enthusiastically  adopted  at  first,  but  its  truths  soon  began  to  impress  them- 
selves upon  the  profession,  so  that  by  the  time  Koch  made  his  discovery  they 
-were  ready  to  go  to  extremes.  The  great  discoverer  himself  believed  for  a  time 
that  he  had  discovered  a  panacea  for  all  who  were  afflicted  with  tuberculosis, 
and  the  majority  of  the  profession  began  the  use  of  his  lymph  with  enthusiasm, 
only  to  be  disappointed.  Since  that  time  the  development  of  surgical  technique 
has  been  rapid  and  steady,  until  it  has  reached  such  a  state  of  perfection  that 
we  are  in  danger  of  thinking,  as  did  Ambroise  Pare,  that  there  are  but  few  things 
posterity  can  add.  Within  the  experience  of  many  surgeons  still  in  active  prac- 
tice, we  have  passed  from  old-time  or  septic  surgery  to  aseptic  or  present-day 
surgery.  The  keynote  to  modern  surgical  technique  is  surgical  cleanliness,  and 
this  is  best  secured  by  a  happy  combination  of  the  principles  of  antisepsis  and 
asepsis.  For  a  number  of  years  during  the  development  of  our  present  technique 
our  medical  journals  teemed  with  articles  upon  this  subject,  but  at  the  present 
time  an  article  on  technique  is  considered  unnecessary.  This  is  a  dangerous 
attitude,  because  a  belief  that  we  have  arrived  at  the  acme  of  human  perfection 
will  surely  prevent  progress.  The  great  benefits  vouchsafed  mankind  through 
this  gospel  of  cleanliness  are  not  without  alloy.  The  fact  that  such  wonderful 
things  can  be  done  through  a  clean  wound  has  led  to  the  doing  of  many  un- 
warrantable things.  There  is  too  much  of  a  tendency  among  young  members  of 
the  profession  to  believe  that  technique  is  all  there  is  of  surgery,  and  that  as 
soon  as  a  man  can  secure  healing  by  first  intention  he  is  a  surgeon.  There  is 
decidedly  too  great  a  tendency  to  make  a  diagnosis  with  the  knife.  Operations 
are  a  very  necessary  part  of  surgery,  but  it  is  more  important  to  decide  when 
and  when  not  to  operate.  It  sometimes  requires  more  courage  to  decide  not  to 
operate  than  to  operate.  The  surgeon  should  always  be  bold  but  conservative, 
for  conservatism  is  the  greatest  attribute  of  a  good  surgeon.  The  conservative 
surgeon  will  operate  only  when  he  believes  that  an  operation  is  the  treatment 
most  likely  to  save  the  life  of  his  patient  or  to  restore  him  to  health.  He  is  al- 
ways open  to  conviction,  but  does  not  accept  statements  because  they  are  new, 
nor  does  he  discredit  established  facts  because  they  are  old.  It  is  not  conserva- 
tism to  refuse  to  operate  when  an  operation  is  clearly  indicated.  The  knife  is 
often  the  greatest  of  conservative  agents. 

There  are  cases  in  which  an  exploration  is  the  only  possible  means  of  making 
an  accurate  diagnosis,  and  it  is  then  not  only  justifiable  but  advisable;  but  it 
should  be  a  court  of  last  resort.  The  fact  that  it  can  be  done  by  competent 
surgeons  with  very  little  danger  gives  them  no  license  to  resort  to  it  without 
first  having  exhausted  all  other  known  means  of  diagnosis.     Unfortunately, 


GENERAL  SURGICAL  TREATMENT.  693 

there  are  a  good  many  operators,  some  of  them  very  skilful  too,  who  are  not 
surgeons.  A  surgeon,  except  in  an  emergency;  takes  ample  time  to  study  his 
cases  before  advising  for  or  against  an  operation,  while  a  mere  operator  is  prone 
to  operate  without  this  preliminary.  The  result  is  that  many  unnecessary  and 
unwise  operations  are  performed,  and  surgery  is  brought  into  disrepute.  The 
surgeon  watches  his  patients  carefully  after  the  operation,  because  he  feels  that 
he  has  not  performed  his  whole  duty  until  the  patient  is  fully  restored  to  health; 
but  one  who  thinks  that  operations  are  the  whole  of  surgery  too  often  neglects 
the  after-treatment,  turning  the  patient  over  to  the  nurse.  Every  young  man 
should  begin  by  studying  his  cases  carefully  and  keeping  a  written  record  of 
them,  for  in  this  way  he  accomplishes  the  most  good  for  his  patient  and  he 
profits  by  his  experience.  When  one  begins  his  professional  career  in  this  man- 
ner, he  establishes  good  habits  and  becomes  a  broader  and  better  practitioner. 

At  the  present  day,  when  hospitals  are  so  numerous,  no  man  who  is  ambi- 
tious to  do  surgery  should  consider  his  education  complete  without  a  ho,s[)ital 
training.  In  after-years  he  will  realize  that  his  hospital  experience  is  the  best 
part  of  his  education.  The  greater  his  natural  endowment  and  ambition  and 
the  better  his  education,  the  more  imperative  is  this  practical  education, 
because  nothing  is  more  dangerous  than  misguided  talent  and  energy.  Another 
way  of  getting  this  practical  experience,  which  is  equal  to,  if  not  better  than, 
hospital  experience,  is  to  act  as  assistant  to  some  surgeon  who  is  doing  good 
work. 

The  most  of  surgery  should  be  learned  before  technique,  but  without  good 
technique  one  cannot  be  a  surgeon.  The  personal  equation  makes  ofttimes  the 
whole  difference  between  success  and  failure.  Some  men  seem  to  be  possessed 
of  an  aseptic  conscience  and  will  always  do  the  clean  thing  without  giving  it  spe- 
cial thought,  while  others  need  some  one  specially  appointed  to  watch  them.  The 
former,  should  he  need  a  chair  in  the  midst  of  an  operation,  will  intuitively  reach 
for  it  with  his  foot,  while  the  latter  will  use  his  hand  and  will  then  introduce  this 
possibly  septic  hand  into  the  wound.  Some  operators  accomplish  the  most  per- 
fect results  attainable  by  a  very  simple  technique,  while  others,  with  a  most 
elaborate  technique,  fail  to  get  good  results.  The  one  understands  and  prac- 
tises the  principles  of  asepsis ;  the  other  does  not.  The  one  grasps  the  situation ; 
the  other  does  not. 

The  best  operators  are  not  always  the  best  surgeons,  but,  other  things  being 
equal,  a  clever  operator  is  the  best  surgeon.  A  very  skilful  operator  may  be  a 
poor  surgeon,  but  a  good  surgeon  owes  it  to  himself  and  his  patients  to  cultivate 
manual  dexterity.  A  good  operator  works  rapidly  without  seeming  to  hurry. 
Unseemly  haste  and  extreme  slowness  are  both  to  be  depreciated.  Time  cer- 
tainly is  an  element  of  success  in  a  surgical  operation.  The  best  operator  is  the 
one  who  can  do  the  maximum  amount  of  good,  clean  work  in  the  minimum 
amount  of  time.    One  who  is  naturally  endowed  with  mechanical  dexterity  has 


694  AMERICAN  PRACTICE   OF  SURGERY. 

a  very  great  advantage  as  an  operator,  but  every  one  who  is  ambitious  to  be- 
come a  surgeon,  no  matter  what  his  natural  quaUfications,  should  nialie  a  care- 
ful study  of  the  mechanical  part  of  his  work.  The  swift,  gliding  motion  of  the 
knife  that  cleaves  the  tissues  without  seeming  to  press  upon  them,  the  dextroas 
tying  of  a  surgeon's  knot,  the  quick,  certam  grasping  of  a  spurtmg  blood-vessel, 
and  the  gentle  handling  of  the  tissues  are  all  evidences  of  good  operating.  Ambi- 
dexterity is  a  natural  gift  of  very  few,  but  it  can  and  should  be  cultivated  by 
every  operator.  Every  young  man  should  begin  by  using  whichever  hand  is 
most  convenient  for  the  work  that  is  to  be  done,  no  matter  how  clumsy  he  may 
be  at  first,  for  ambidexterity  can  be  acquired  by  every  operator  by  persistent 
effort,  and,  when  once  acquired,  it  is  equivalent  to  an  extra  assistant.  A  good 
surgeon  is  always  careful  not  to  destroy  or  injure  any  tissue  unnecessarily,  and 
at  the  same  time  he  uses  every  means  at  his  command  to  avoid  or  destroy 
bacteria.  The  anatomical  operating  methods  of  our  forefathers  are  infinitely 
superior  to  the  rough  methods  too  often  practised  to-day.  Blunt  dissections 
by  fingers  or  instrmnents  should  be  employed  only  when  the  exigencies  of  the 
case  demand  it. 

Modern  surgical  technique  is  made  up  of  many  little  details.  Each  detail  is 
a  link  of  a  chain  which  when  completed  makes  a  perfect  surgical  operation,  and 
every  necessary  detail  omitted  makes  a  weak  spot  in  the  chain.  The  measure  of 
perfection  of  an  operation,  however,  is  the  simplicity  of  its  detail.  The  operator 
who  knows  least  of  aseptic  surgical  technique  is  the  one  who  makes  the  greatest 
display.  Simplicity  of  technique  should  be  cultivated,  because  every  unneces- 
sary detail  is  an  element  of  weakness  which  tends  to  bring  the  method  into  dis- 
repute. A  novice  is  much  more  likely  to  succeed  with  a  simple  technique  than 
with  an  elaborate  one.  When  the  method  is  too  elaborate  he  is  apt  to  forget 
some  part  or  to  conclude  that  it  is  unnecessary,  and  he  may  be  incompetent  to 
decide  what  is  and  what  is  not  essential,  for  what  is  essential  can  be  established 
only  by  bacteriologic  experiments.  "Wlien  one  without  initiative,  but  who  is 
simply  doing  what  he  has  been  told  to  do,  discovers  accidentally  that  he  can 
omit  some  detail  which  he  has  been  taught  was  essential,  without  serious  conse- 
quences, he  is  very  apt  to  conclude  that  there  are  others  which  can  be  omitted, 
and  the  end  will  be  disastrous.  Wlien  the  minimum  requirements  for  aseptic 
surgery  are  employed,  they  appeal  to  the  beginner  as  rational  and  therefore  es- 
sential, and  he  will  not  neglect  them.  Just  what  the  minimum  requirements 
are  cannot  be  definitely  settled,  because  they  differ  with  men  and  environment. 
Each  operator  should  follow  a  definite  routine  in  his  asepsis,  and  he  will  thus 
learn  what  his  person  and  his  environment  require;  and,  having  once  estab' 
lished  a  technique  which  brings  about  the  desired  results,  he  should  adhere  to  it 
until  he  is  satisfied  he  can  make  a  change  for  the  better.  Change  for  sake  of 
change  should  be  avoided.  No  one  can  be  a  safe  surgeon  who  is  not  thoroughly 
imljued  with  the  principles  of  asepsis,  for  without  this  he  will  be  doing  things 


GENERAL  SURGICAL  TREATMENT.  695 

just  because  some  one  has  told  him  to,  and  cannot  appreciate  their  value. 
When  a  surgeon's  ideas  of  cleanliness  are  the  same  as  those  of  a  mother  when 
she  washes  her  child's  face,  he  is  certain  to  be  careless  and  to  handle  unsterilized 
articles  after  he  has  prepared  his  hands;  but  when  he  thoroughly  understands 
that  the  cleansing  of  hands  and  everything  connected  with  an  operation  means 
sterilization  or  the  removal  of  bacteria,  he  will  understand  the  necessity  for 
avoiding  contact  with  unsterilized  articles,  and  that  every  unsterilized  article  is 
a  possible  source  of  infection. 

Sepsis  is  the  condition  following  the  introduction  of  pyogenic  bacteria  into  a 
wound.    Sepsis  is  caused  only  by  bacterial  invasion. 

.  Antisepsis  is  the  term  used  for  designating  the  various  methods  employed  to 
destroy  or  inhibit  the  growth  of  bacteria  in  a  wound. 

Antiseptics  are  the  drugs  and  other  agents  employed  to  destroy  or  inhibit 
bacteria. 

Antiseptic  surgery  is  the  name  given  to  the  technique  taught  by  Lister 
which  was  practised  for  many  years.  Lister  believed  that  the  air  was  the  prin- 
cipal carrier  of  germs,  and  that  it  was  necessary,  in  the  case  of  every  womid 
exposed  to  that  element,  to  use  antiseptics  for  the  purpose  of  destroying 
these  germs.  He  impregnated  the  atmosphere  of  the  operating-room  with 
carbolic  spray,  and  it  was  made  to  play  over  the  hands  of  the  operator  and  the 
field  of  operation  constantly.  Instruments  and  ligatures  were  prepared  by  im- 
mersion in  carbolic  lotion.  The  spray  was  very  disagreeable  to  the  operator 
and  sometimes  produced  some  unpleasant  effects  in  the  patient,  so  that  it  was 
soon  abandoned.  Before  the  establishment  of  the  germ  theory  surgeons  believed 
that  in  some  mysterious  way  the  air  caused  inflammation  in  a  wound.  In  1841 
Stromeyer  performed  subcutaneous  tenotomy,  and  this  was  followed  by  many 
subcutaneous  operations,  the  object  being  to  prevent  the  entrance  of  air.  It 
has  been  conclusively  demonstrated  that  the  atmosphere  plays  a  minor  part  in 
wound  infection,  but  a  dust-laden  atmosphere  is  to  be  avoided,  because  every 
particle  of  dust  may  act  as  a  carrier  of  germs.  This  Icnowledge  has  led  to  a 
gradual  change,  so  that  the  term  applied  to  modern  surgical  technique  is  aseptic 
surgery. 

Asepsis  means  the  absence  of  living  pathogenic  bacteria,  and  when  practis- 
ing aseptic  surgery  we  endeavor  to  destroy  and  remove  all  micro-organisms  from 
everything  connected  with  the  operation,  so  that  we  may  have  an  aseptic  wound. 
It  is  claimed  that  an  absolutely  aseptic  wound  is  an  impossible  condition,  but 
the  natural  resisting  powers  of  the  tissues  are  sufficient  to  destroy  a  limited 
number  of  bacteria,  and  when  we  keep  the  number  entering  a  wound  within  that 
limit  we  have  achieved  practical  asepsis. 

The  essential  difference  between  antiseptic  and  aseptic  surgery  is  that  in  the 
former  the  germs  have  supposedly  gained  entrance  to  the  wound  and  an  effort  is 
made  to  destroy  them  there  by  chemical  antiseptics,  whereas  in  the  latter  we 


696  a:\ierican  practice  of  surgery. 

endeavor  to  preA'ent  their  entrance  into  the  wound,  ilost  surgeons  practise 
both  aseptic  and  antiseptic  surgery,  but  the  nearer  we  get  to  asepsis  the  nearer 
we  are  to  perfection.  It  is  certainly  better  to  prevent  the  entrance  of  germs  into 
a  wound  than  to  destroy  them  there,  leaving  their  dead  or  possibly  only  inhibited 
bodies.  The  chemical  solutions  used  as  antiseptics  interfere  with  imion  and  may 
cause  poisoning.  "\'\1ien  the  wound  is  an  accidental  one  and  not  of  the  surgeon's 
making,  it  must  be  treated  antiseptically,  and  in  preparing  for  an  aseptic  opera- 
tion more  or  less  antiseptics  are  used.  The  chief  danger  in  practising  antiseptic 
surgery  is  that  the  surgeon  may  place  too  much  dependence  upon  his  chemicals 
and  be  careless  about  the  entrance  of  bacteria  into  the  wound.  Present-day 
operative  surgery  demands  that  whatever  of  antisepsis  is  practised  should  be 
before  the  operation  and  that  asepsis  be  maintained  during  and  after  the  opera- 
tion. It  has  been  clearly  demonstrated  that  chemicals  introduced  into  a  clean 
wound  do  no  good,  but  do  some  harm.  There  is  no  longer  room  for  controversy 
as  to  the  comparative  merits  of  antiseptic  and  aseptic  surgery,  because  at  the 
present  time  the  term  used  is  not  applied  so  much  to  methods  as  to  results.  A 
sterile  wound  is  an  aseptic  wound,  and  a  surgeon  who  secures  such  wounds  is 
practising  aseptic  surgery,  no  matter  how  he  brings  it  about.  Some  English 
surgeons  are  quite  pessimistic  about  the  future  of  wound  healing,  because  we  are 
drifting  farther  from  the  original  antiseptic  methods,  but  the  fact  is  that  the 
percentage  of  aseptic  wounds  is  greater  now  than  at  any  period  in  the  history  of 
surgery.  No  matter  what  method  we  employ,  the  principles  are  those  taught  us 
by  Lister. 

INFECTION. 

AATien  bacteria  sufficient  in  number  or  virulence  to  overcome  the  natural  re- 
sisting powers  of  the  tissues  have  gained  entrance  to  a  woimd,  it  is  infected. 
The  evidences  of  infection  are  inflammation,  suppuration,  and  a  whole  train  of 
accompanying  symptoms  only  too  familiar  to  every  surgeon. 

It  is  no  longer  necessary  to  state,  when  reporting  a  surgical  operation,  that 
"every  antiseptic  precaution  was  observed,"  because  the  necessity  for  these  pre- 
cautions is  so  well  understood  by  the  laity  as  well  as  the  profession  that  any 
one  undertaking  an  operation  without  them  might  be  held  guilty  of  malpractice. 
It  is  just  as  important  to  observe  every  precaution  during  the  operation  as  be- 
fore it,  for  then  nature's  protection,  the  skin  or  mucous  membrane,  is  broken, 
making  an  entrance  way  for  the  ubiquitous  germ.  It  is  in  these  preparations  and 
precautions  that  the  operator  shows  his  surgical  training.  One  without  proper 
training  is  prone  to  feel  that,  having  thoroughly  prepared  himself  and  his  pa- 
tient, he  has  performed  his  whole  duty,  and  is  liable  to  be  careless  during  the 
operation.  Proper  preparation  of  surgeon  and  patient  means  sterilization,  and 
after  sterilization  every  source  of  contamination  must  be  avoided.  No  matter 
how  perfect  an  operating-room,  it  contains  some  things  that  are  not  sterile,  and 


GENER.4L  SURGICAL  TREATMENT.  697 

contact  of  the  surgeon's  hands,  instruments,  Hgatures,  and  dressings  with  these 
unsteriUzed  things  means  contamination.  In  order  thoroughly  to  appreciate  the 
dangers  of  contamination  from  these  seemingly  harmless  sources,  a  knowledge 
of  bacteriology  is  absolutely  necessary.  The  surgeon  should  be  familiar  with  the 
different  varieties  of  bacteria  and  their  distribution  in  the  outer  world.  He 
should  know  their  ways  of  entrance  into  and  exit  from  the  body  and  the  condi- 
tions which  favor  their  development  in  a  wound.  It  is  only  with  this  knowledge 
that  he  can  rationally  guard  against  their  entrance  and  development.  Every 
surgeon  cannot  be  a  bacteriologist  any  more  than  every  bacteriologist  can  be  a 
surgeon,  but  no  man  can  be  a  thorough  surgeon  without  a  practical  knowledge 
of  bacteriology.  To  such  a  surgeon  the  contact  of  a  sterilized  hand  with  an 
unsterilized  object  is  apt  to  mean  the  transfer  of  pathogenic  bacteria  from  this 
object  to  the  hand.  The  prepared  surgeon  should  never  touch  any  part  of  the 
patient  which  is  not  sterile.  He  must  not  put  his  hands  into  his  pockets,  scratch 
his  head,  stroke  his  beard,  or  blow  his  nose;  he  must  not  handle  his  eyeglasses 
nor  pick  things  from  the  floor.  One  who  habitually  makes  these  mistakes  shows 
lack  of  either  surgical  training  or  surgical  sense.  It  is  men  of  this  type  who  are 
constantly  having  suppurating  wounds  and  stitch  abscesses,  for  which  they  usu- 
ally hold  the  nurses,  the  assistants,  or  the  catgut  responsible.  These  tangible 
surroundings  are  the  fruitful  sources  of  infection,  against  which  the  surgeon 
must  be  constantly  on  guard.  In  every  hospital,  in  spite  of  every  known  pre- 
caution, cycles  of  infection  occur,  in  which  a  number  of  cases  are  involved  in 
close  succession.  This  can  sometimes  be  traced  to  one  septic  case  which  has 
acted  as  a  focus,  but  many  times  the  source  is  never  discovered.  When  these 
infections  occur  in  the  work  of  one  individual,  he  is  septic,  and  if  he  cannot  be- 
come sterile  he  should  quit  work  for  a  time.  Wien  the  trouble  is  general  there  is 
a  weak  spot  in  this  respect  somewhere  in  the  institution,  and  the  only  way  to 
overcome  it  is  for  every  one,  from  the  surgeon  down  to  the  humblest  nurse  who 
has  anything  to  do  with  preparation  or  sterilization,  to  assume  that  he  or  she  is 
individually  responsible  for  the  trouble  and  to  act  accordingly.  It  is  possible 
that  these  infections  are  from  intangible  sources,  but  our  present  knowledge 
of  infections  demands  that  we  act  as  if  they  were  due  to  overlooked  tangible 
sources.  These  cycles  will  often  be  traced  to  the  misdeeds  of  some  one  who  does 
not  understand  the  principles  involved. 

Portals  of  Entrance  and  Sources  of  Bacteria  in  Surgical  Infections. 

Certain  bacteria  have  their  habitat  in  the  human  body — for  example,  the 
colon  bacillus  in  the  intestines  and  the  white  staphylococcus  of  Welch  in  the 
deeper  layers  of  the  epidermis — and  it  is  these  bacteria  which  make  auto-infec- 
tion possible.  It  is  not  definitely  known  how  all  bacteria  are  eliminated  from 
the  body,  but  a  natural  inference  is  that  the  excretory  organs  have  this  as  one 


698  AMERICAN  PRACTICE  OF  SURGERY. 

of  their  many  functions;  hence  the  importance,  for  an  operation,  of  a  prepara- 
tory course  of  treatment  which  shall  carefully  regulate  these  organs.  Bacteria 
cannot  gain  entrance  mto  the  body  directly  through  the  skin,  but  may  enter 
through  the  numerous  natural  openings,  such  as  hair  follicles  and  sebaceous 
glands.  Recent  observations  teach  that  the  sweat  glands  rarely  afford  an 
entrance  waj'  for  bacteria,  and  that  the  danger  of  infection  from  sweating 
hands  has  been  greatly  overestimated.  Harrington  made  repeated  examina- 
tions of  sweat  obtained  from  sterilized  hands  and  arms  and  placed  in  heated 
sterile  glass  cylinders,  and  in  every  instance  found  it  sterile.  The  sweat 
dropping  from  an  unsterUized  face  or  beard  is,  of  course,  an  entirely  different 
matter. 

The  most  common  entrance  way  of  bacteria  is  through  a  wound  in  the  skin. 
The  danger  of  infection  through  a  wound  is  not  in  proportion  to  its  size,  the 
smaller  wound  often  being  the  more  dangerous.  In  operative  surgery  the  great 
danger  is  that  bacteria  may  be  introduced  into  the  wound  by  dirty  hands,  m- 
strmnents,  ligatiu-es,  or  dressings.  Tlie  surgeon  and  his  co-workers  are  the  guards 
whose  duty  it  is  to  prevent  mfection,  and  the  various  antiseptics  and  methods 
of  sterilization  are  their  weapons.  Before  the  daj^s  of  Lister  the  surgeon  was  not 
responsible  for  wound  healing,  but  now  "  the  fate  of  the  womid  rests  m  the  hands 
of  the  one  who  applies  the  first  dressing."  Flies  and  other  insects  may  infect  a 
woimd  by  carrj^uig  bacteria  or  through  their  excreta.  Pyogenic  staphylococci 
have  been  foimd  in  the  excrements  of  flies.  There  are,  therefore,  more  potent 
reasons  for  excluding  flies  from  hospitals  than  the  comfort  of  the  patients. 

Since  it  has  been  demonstrated  that  Lister  laid  undue  stress  upon  infection 
through  the  air,  it  is  quite  possible  we  have  gone  to  the  other  extreme  and  do 
not  pay  enough  attention  to  this  possible  source  of  infection.  Just  how  great  the 
dangers  of  infection  through  the  air  are  is  still  a  matter  of  controA^ersy.  Bac- 
teriologists and  surgeons  are  somewhat  at  variance  in  this  matter,  for  while  the 
former  can  demonstrate  the  presence  of  bacteria  in  the  atmosphere  of  every  oper- 
atmg-room,  the  latter  can  show  a  long  series  of  aseptic  womids  without  any 
special  precautions  having  been  taken  against  air  infection.  Sea  air,  where  there 
is  no  dust,  and  sometimes  high  mountain  air  are  free  from  bacteria,  but  they  are 
always  present  in  air  near  the  gromid  where  there  is  dust.  They  are  more  nu- 
merous in  the  city  than  m  the  country,  and  are  often  more  numerous  in  hospital 
wards  than  elsewhere.  The  fact  that  aseptic  work  can  be  done  m  a  germ-laden 
atmosphere  proves  that  the  number  of  pathogenic  bacteria  carried  in  that  way  is 
not  so  great  as  to  overcome  the  natural  resistmg  powers  of  the  tissues.  Indi- 
rectly, however,  the  air  is  a  dangerous  source  of  infection.  Bacteria  are  carried 
on  particles  of  dust,  which  have  a  natural  tendency  to  settle  and  accumulate  on 
tangible  objects,  which  may  cause  contact  infection.  Womids  should  be  pro- 
tected from  a  dust-laden  atmosphere.  This  can  be  accomplished  by  moisture, 
which  encourages  the  natural  tendencv  of  the  dust  to  settle. 


GENERAL  SURGICAL  TREATMENT.  699 

All  manner  of  bacteria  are  constantly  found  in  the  mouth,  nose,  and  throat; 
so  it  is  only  rational  to  conclude  that  they  may  be  carried  into  a  wound  by  the 
breath  of  the  surgeon  or  his  assistants.  It  has  been  maintained  that  air  is  steri- 
lized as  it  passes  through  the  lungs,  and  that  the  lungs  are  free  from  bacteria. 
Even  if  this  be  true,  air  becomes  contaminated  on  passing  through  the  mouth, 
for  breathing  into  culture  media  will  almost  invariably  yield  cultures.  One 
hospital  bacteriologist,  after  having  the  internes  in  his  hospital  breathe  into 
media  several  times,  was  able  to  tell,  from  the  character  of  the  cultures,  which 
interne  had  breathed  into  a  certain  medium.  No  one  with  a  sore  throat  should 
be  allowed  to  come  near  a  wound.  It  has  been  demonstrated  by  careful  ob- 
servers that  in  ordinary  conversation  minute  droplets  of  saliva  are  being  con- 
stantly thro'mi  out  in  all  directions,  and  these  same  observers  have  proven  that 
saliva  may  be  richer  in  bacteria  than  the  foulest  sewage.  It  would  seem,  in 
face  of  these  facts,  that  a  surgeon  who  would,  as  nearly  as  possible,  remove 
every  source  of  infection,  must  either  refrain  from  talking  into  the  wound  or 
wear  a  mask.  The  chances  of  infection  through  the  breath  must  be  very 
remote,  because  the  moist  surface  of  the  nose  and  mouth  will  surely  capture 
most  of  the  bacteria,  but  the  dangers  from  the  saliva  are  well  worth  considering. 

Conditions  Favorable  to  the  Development  of  Infection   in 

Wounds. 

Bacteria  are  plants,  and  like  all  other  plants  require  certain  conditions  for 
their  growth  and  development.  Unfortunately,  a  wound  affords  many  of  these' 
conditions.  There  are,  m  a  wound  favorable  to  the  development  of  bacteria, 
many  general  underlying  conditions  for  which  the  surgeon  is  in  no  way  respon- 
sible; and,  since  it  is  impossible  for  him  to  prevent  the  entrance  of  some  germs 
into  the  womid,  it  is  his  duty  to  remove  or  prevent  every  condition  favorable  to 
their  development  that  he  possibly  can.  Every  operation  is  said  to  be  an 
experiment  in  bacteriology  and  pathology,  but  we  have  learned  that  a  wound 
infection  is  a  vastly  different  affair  from  the  artificial  infection  of  a  culture 
medium  in  a  laboratory;  because  the  living  tissues  fiu-nish  so  many  complex 
conditions,  both  against  and  in  favor  of  the  development  of  bacteria,  that  the 
results  following  their  entrance  into  a  wound  cannot  be  definitely  foretold. 
The  surgeon  cannot  solve  problems  in  bacteriology  without  a  bacteriologist, 
but  the  fact  that  his  culture  field  is  a  wound  in  living  tissues  enables  him  to 
discover  some  clinical  bacteriologic  facts  that  cannot  be  discovered  through 
a  dead  medium.  This  accounts  for  the  occasional  difference  between  the  bac- 
teriologist and  the  surgeon.  It  must  be  admitted,  however,  that  most  of  these 
differences  are  explained  by  the  fact  that  the  surgeon  too  often  indulges  in 
post-hoc  reasoning  and  attributes  certain  clinical  results  to  something  he  has 
done  or  used  which  really  had  no  bearing  in  the  matter. 


700  AMERICAN  PRACTICE  OF  SURGERY. 

There  are  inherent  in  individuals  many  conditions  that  favor  the  development 
of  infections — conditions  that  are  spoken  of  as  predispositions.  These  conditions 
are  not  well  enough  imderstood  to  enable  us  to  draw  many  practical  conclusions 
concerning  them,  and  the  more  we  learn  of  the  habits  of  bacteria  the  less  stress 
we  lay  upon  predispositions,  because,  the  local  conditions  being  favorable,  bac- 
teria will  develop  in  all  ages  and  conditions  of  human  beings.  It  is  well  under- 
stood that  the  extremes  of  age,  anajmia,  diabetes,  and  Bright's  disease  are 
favorable  to  the  development  of  infections,  presumably  from  a  diminution  of  the 
natural  resisting  powers  of  the  tissues  under  these  conditions. 

There  is  a  great  difference  in  the  natural  virulence  of  pathogenic  bacteria,  the 
colon  bacillus  and  the  streptococcus  being  respectively  fair  representatives  of 
the  mildest  and  most  virulent  of  the  pyogenic  micro-organisms.  The  number  of 
bacteria  entering  a  wound  doubtless  has  a  decided  bearing  upon  the  early  his- 
tory of  an  infection,  but  the  natural  tendency  is  for  them  to  multiply  so  rapidly 
that  this  is  probably  not  a  lasting  factor.  The  source  of  an  infection  has  a  very 
decided  bearing  upon  its  virulence.  Pathologists  teach  that  the  virulence  of 
bacteria  depends  largely  upon  their  ability  to  form  toxic  products  through  which 
they  produce  their  pathogenic  effects.  The  extreme  virulence  of  infections  com- 
ing directly  from  the  human  body  is  doubtless  due  to  the  recently  acquired 
habits  of  the  bacteria,  and  to  the  fact  that  toxic  products  are  introduced  with 
them. 

Tissues  vary  somewhat  in  their  susceptibilities  to  infection  and  in  the  path- 
ological changes  that  result  from  infection.  The  dense,  highly  vascular  tissues, 
such  as  the  lips,  cheeks,  and  tongue,  have  so  great  a  resisting  power  as  to  have 
often  brought  aseptic  technique  into  considerable  disrepute  in  the  minds  of  those 
already  disposed  to  question  its  value,  because  primary  union  will  usually  take 
place  in  these  tissues  even  when  aseptic  precautions  have  been  very  scant  or 
inefficient.  On  the  other  hand,  synovial  membranes,  the  medullary  tissue  of 
bone,  and  adipose  and  loose  connective  tissue  are  exceptionally  susceptible  to 
pyogenic  infection.  Normal  mucous  membranes  are  very  resistant  to  microbic 
invasion,  but  a  paralyzed  bladder  is  very  easily  infected.  Their  exceptional 
resisting  power  is  very  helpful  to  the  surgeon,  because  it  is  almost  impossible 
to  sterilize  a  mucous  membrane  when  preparing  for  an  operation.  There  is 
probably  no  greater  contrast  in  this  respect  than  that  between  the  peritoneum 
and  joint  surfaces.  The  peritoneum  was  considered  by  old-time  surgeons  their 
greatest  enemy,  because  their  wounds  were  all  septic,  and  a  traumatic  septic 
peritonitis  is  practically  a  hopeless  condition.  With  our  present  knowledge  of 
infection,  however,  we  know  that  the  peritoneum  is  the  surgeon's  greatest 
friend,  because  of  its  wonderful  ability  to  care  for  itself.  Joint  surfaces  have  a 
very  low  resisting  power  and  are  very  liable  to  infection.  No  one  who  is  uncer- 
tain of  his  asepsis  should  open  a  joint,  because  he  is  almost  certain  to  have  an 
infection.    The  older  surgeons  recognized  the  dangers  of  an  infection  of  a  joint, 


GENERAL  SURGICAL  TREATMENT.  701 

but  they  did  not  fear  it  as  they  did  peritoneal  infection,  because  it  is  possible 
to  drain  an  infected  joint  and  restore  the  patient  to  health,  and  sometimes  to 
preserve  the  function  of  the  joint. 

A  ragged  wound  caused  by  injury  or  rough  handling  and  dissecting  is  better 
soil  for  the  growth  of  bacteria  than  a  clean  cut.  Blunt  dissections  and  too  heavy 
or  prolonged  pressure  bj''  retractors  are  to  be  avoided.  Necrotic  tissue  from  any 
source  offers  food  for  germs.  Masses  of  tissue  should  not  be  strangulated  by 
ligatures  or  forceps.  Ligatures  and  sutures  must  never  be  tied  tighter  than  is 
absolutely  necessary.  One  serious  objection  to  chemicals  in  a  wound  is  that 
they  are  liable  to  cause  necrosis  of  tissues,  thus  inviting  infection.  Foreign 
bodies,  such  as  drainage  tubes  and  unabsorbable  ligatures,  interfere  mechan- 
ically with  wound  healing  and  encourage  bacterial  growth.  Drainage  tubes 
cannot  be  dispensed  with  altogether,  but  should  always  be  considered  a  neces- 
sary evil.  Many  surgeons  still  use  silk  for  buried  sutures  and  get  good  results, 
except  in  a  certain  percentage  of  cases  in  which  they  cause  abscesses  and  fistulse; 
but  one  who  has  become  familiar  with  the  use  of  catgut  is  never  content  with 
silk.  Tension  in  a  wound  from  any  cause  encourages  bacterial  development  by 
interfering  with  the  circulation  and  thus  reducing  the  resisting  power  of  the  tis- 
sues. Careful  hfemostasis  is  a  very  essential  part  of  aseptic  surgery.  Hemor- 
rhage in  a  wound  causes  tension  and  interferes  mechanically  with  healing  by 
keeping  the  tissues  apart.  Bactericidal  properties  have  been  attributed  to  liv- 
ing blood  and  blood  serimi,  but  dead  blood  affords  nourishment  for  bacteria. 
Blood  serum  is  being  used  constantly  as  a  culture  medium  in  laboratories.  It 
is  an  open  question  whether  the  bactericidal  properties  attributed  to  blood  serum 
are  not  due  to  living  cells  known  to  be  the  enemies  of  bacteria.  Be  this  as  it 
may,  all  practical  surgeons  agree  that  a  blood  clot  in  a  wound  is  an  element  of 
danger  to  be  avoided  whenever  possible.  There  are  times,  however,  when  dead 
space  is  miavoidable,  and  then  a  blood  clot  is  our  best  resource.  In  the  soft 
tissues  no  artificial  substance  has  been  found  so  satisfactory  for  filling  as  blood 
clot,  and  until  a  very  recent  date  Schede's  method  of  filling  bone  cavities  with 
aseptic  blood  clot  was  the  best  method  kno^ra.  Of  late,  however,  Mosetig  has 
given  us  an  artificial  filling  which  is  better.  Every  effort  should  be  made  by 
the  surgeon  closely  to  approximate  the  tissues  so  as  to  leave  no  dead  space  to 
be  filled  with  the  body  fluids.  AVlien  dead  space  cannot  be  overcome  without 
undue  pressure  from  bandages  or  sutures,  it  is  safer  to  depend  upon  nature  to 
fill  the  cavities. 

DISINFECTION  AND  STERILIZATION. 

Disinfection  and  sterilization  are  the  terms  applied  to  the  various  methods 
of  destroying  micro-organisms  and  rendering  sterile  everything  pertainmg  to  a 
wound.    The  means  employed  are  mechanical,  chemical,  and  dry  or  moist  heat. 


702  AMERICAN  PRACTICE  OF  SURGERY. 

The  most  reliable  agent  is  moist  heat  through  steam.  Absolute  sterilization  of 
instruments,  dressings,  and  ligatures  is  possible  by  heat,  but  absolute  steriliza- 
tion of  hands  and  skin  is  impossible,  because  heat  of  sufficient  intensity  can- 
not be  employed,  and  we  are  obliged  to  depend  upon  mechanical  and  chemical 
agents. 

Skin  Sterilization. 

Volumes  have  been  written  on  the  subject  of  skin  disinfection  during  the 
evolution  of  aseptic  surgery,  and  the  end  is  not  yet  and  possibly  never  will  be, 
because  perfection  would  seem  to  be  unattainable.  Practical  sterilization,  how- 
ever, is  attainable,  and  the  more  exacting  our  methods  to  achieve  it  the  nearer 
we  approach  perfection.  There  is  no  one  accepted  method,  but  there  are  many 
good  ones.  It  is  not  so  much  the  method  chosen  as  the  conscientiousness  with 
which  the  chosen  method  is  carried  out,  which  leads  to  results. 

Mechanical  Purification. 

American  surgeons  are  practically  unanimous  in  their  opinion  that  mechan- 
ical cleansing  by  means  of  soap  and  brush  is  the  most  essential  and  reliable 
means  of  skin  disinfection.  This  is  usually  supplemented  by  chemical  aids,  but  the 
amount  of  chemicals  used  has  gradually  grown  less  and  less,  so  that  at  the  present 
time  many  surgeons  place  very  little  dependence  upon  them.  The  skin  cannot  be 
properly  disinfected  by  chemicals  alone.  Thorough  scrubbing  will  under  ordi- 
nary circumstances  render  them  superfluous,  but  they  are  still  considered  a  valu- 
able accessory  by  most  surgeons.  Scrubbing  is  so  often  inefficiently  performed 
that  it  is  wiser  to  employ  some  chemical  accessory  as  a  routine.  A  surgeon 
should  take  good  care  of  his  hands  at  all  times.  He  should  not  do  anything  that 
will  make  them  hard  and  rough,  because  this  diminishes  their  tactile  sense  and 
makes  them  more  difficult  to  disinfect.  Kocher  said  that  the  time  when  a  surgeon 
should  wear  gloves  is  when  he  is  not  operating.  He  should  not  put  his  hands  into 
pus  or  dress  septic  wounds  without  gloves,  for,  in  spite  of  the  most  careful  efforts 
at  sterilization,  the  Staphylococcus  aureus  has  been  found  on  a  surgeon's  hands  for 
several  days  after  handling  septic  cases.  For  mechanical  purification,  soap,  hot 
water,  brushes,  and  nail  cleaners  are  necessary.  Running  hot  water  is  a  great 
advantage  and  should  be  provided  in  every  operating-room.  There  should  be 
foot  attachments,  so  that  the  surgeon  need  never  touch  the  faucet  with  his 
hands.  When  basins  are  used,  the  water  in  them  should  be  frequently  changed 
by  an  assistant.  The  running  water,  besides  being  clean,  aids  mechanically  by 
carrying  off  the  loosened  and  dissolved  dirt. 

Soap  made  by  heat  is  usually  free  from  bacteria,  but  that  used  in  operating- 
rooms  should  be  resterilized.  Soap  dissolves  fat  and  particles  of  dirt  so  that  they 
can  be  more  readily  removed  by  friction  with  gauze  and  brushes.  In  an  emer- 
gency any  good  soap  may  be  used,  but  soaps  impregnated  with  chemicals  have 


GENERAL  SURGICAL  TREATMENT.  703 

proven  unsatisfactory.  The  green  soap  of  the  pharmacopoeia  is  the  best  and  is 
that  in  most  common  use.  It  may  be  used  as  it  is  found  in  drug  stores,  dissolved 
in  water,  or  in  the  form  of  tincture.  The  supply  furnished  for  the  preparation 
of  hands  and  skin  should  be  protected  against  infection.  This  matter  is  too 
often  neglected.  An  open  soap-dish  so  located  that  dirty  hands  and  brushes  can 
be  dipped  into  it  and  dirty  water  splashed  into  it  is  a  source  of  danger.  Hands, 
at  the  beginning  of  preparation  or  in  the  midst  of  an  operation  on  a  pus  case  are 
septic,  and  should  not  be  dipped  into  the  soap  any  more  than  they  should  be 
allowed  to  touch  the  sterile  dressings.  No  matter  how  clean  a  brush  may  be,  it 
cannot  remain  so  after  being  rubbed  over  a  dirty,  possibly  pus-covered  hand. 
Soap  containers  can  now  be  hacl  with  a  valve  in  the  bottom,  which  when  pushed 
up  will  allow  the  liquid  soap  to  flow  into  the  hand.  These  can  be  attached  to- 
the  wall  at  a  convenient  spot  over  the  wash  sink.  Liquid  soap  can  be  put  into 
a  wide-mouthed  sterile  bottle,  and  the  mouth  then  covered  with  sterile  gauze,, 
through  which  the  soap  can  be  poured. 

Brushes  cannot  be  sterilized  by  chemicals,  but  can  be  made  sterile  by  boil- 
ing them  for  five  minutes.  A  longer  boiling  is  unnecessary  and  soon  destroys  the 
brush.  After  every  operation  the  brushes  should  be  thoroughly  washed  so  as  to 
remove  soap  and  gross  dirt,  and  then  boiled.  They  should  then  be  kept  in  a  1  to 
1,000  bichloride  solution  ready  for  use.  A  hog  bristle  brush  of  medium  stiffness 
is  the  best.  Too  stiff  a  brush  injures  the  skin  and  is  uncomfortable,  and  too 
soft  a  brush  will  not  remove  the  dirt.  The  wood  fibre  brush  is  cheap  and  bears 
boiling  better  than  the  bristle  brush,  but  it  is  too  stiff  for  comfort.  It  is  folly  to 
expect  one  brush  to  clean  several  pairs  of  hands  without  reboiling.  Each  sur- 
geon and  assistant  should  have  at  least  two  brushes.  With  the  first  he  should 
loosen  and  remove  all  gross  dirt,  after  which  he  can  finish  the  disinfection  with 
the  second.  The  brushes  should  be  used  freely  on  the  hands,  especially  on  the 
palms  and  about  the  nails,  for  five  or  ten  minutes.  For  the  arms  and  other 
parts  of  the  body  where  the  skm  is  soft,  a  vigorous  scrubbing  with  soap  and  a 
piece  of  gauze  is  better,  as  the  brush 'is  liable  to  cause  abrasions  or  erythema. 

Hand  scrubbing,  in  order  to  be  thorough,  must  be  systematic,  for  otherwise 
some  parts  may  be  untouched.  First,  the  palms  of  the  hands  and  fingers  should 
be  gone  over  thoroughly,  then  the  skin  between  the  fingers,  next  the  nails  and 
dorsum,  each  finger  being  scrubbed  separately,  and  so  oii  until  every  nook  and 
corner  is  thoroughly  cleansed.  This  process  should  be  repeated  continuously 
for  ten  minutes.  A  right-handed  person  is  prone  to  devote  too  large  a  portion 
of  the  allotted  time  to  his  left  hand,  because  it  is  easier  for  him.  A  nail  cleaner 
should  be  used  before,  and  another  sterile  one  several  times  during,  the  scrub- 
bing. All  hangnails  should  be  removed  and  abrasions  touched  with  ninety- 
five-per-cent  carbolic  acid. 

The  skin  at  the  seat  of  operation  is  much  less  likely  to  be  a  source  of  deep 
wound  infection  than  the  surgeon's  hands,  but  should  be  just  as  carefully  pre- 


704  AMERICAN  PRACTICE  OF  SURGERY. 

pared.  The  habitat  of  the  Staphylococcus  albus  of  Welch  is  in  the  deeper  layers 
■of  the  epidermis,  and,  because  of  its  inaccessibility,  is  a  frequent  source  of  stitch 
abscesses  and  mild  superficial  infection  in  spite  of  most  careful  preparation. 
The  seat  of  operation  should  be  carefully  shaved  the  day  before  the  operation 
and  thoroughly  scrubbed.  It  is  customary  in  most  hospitals  to  apply  an  anti- 
septic dressing  at  this  time,  to  be  left  over  night,  but  this  is  not  absolutely  nec- 
essary. Any  wet  or  irritatmg  application  is  objectionable  because  it  interferes 
with  the  patient's  rest.  The  only  advantage  of  this  procedure  is  that  less  time 
will  be  required  to  prepare  the  patient  on  the  operating-table.  No  matter  how 
well  the  parts  have  been  prepared  beforehand,  they  should  be  cleansed  again 
just  before  the  operation.  It  should  be  remembered  that  it  is  quite  possible  to 
overdo  the  scrubbing.  It  is  a  mistake  to  set  up  an  erythema  by  overvigorous 
scrubbing,  by  the  use  of  too  rough  a  brush  or  towel.  Or  by  irritating  applica- 
tions. The  skin  should  not  look  like  a  boiled  lobster,  but  should  have  a  healthy 
pink  glow.  Mustard,  corn  meal,  and  other  substances  having  no  bactericidal 
properties  are  used  by  some  surgeons  for  hand  cleaning,  but  they  act  only  me- 
chanically and  are  inferior  to  soap  and  brush. 

Irrigation  at  one  time  occupied  a  very  important  place  in  surgical  technique, 
solutions  of  various  kinds  being  run  into  wounds  and  cavities  of  all  kinds,  and 
at  that  time  it  was  doubtless  necessary;  but  now  irrigation  is  employed  only 
•occasionally  when  specially  indicated,  and  is  a  mechanical  rather  than  a  chem- 
ical process.  A  fresh  sterile  woimd  should  never  be  irrigated,  because  it  does  no 
good  and  may  do  harm.  The  dry  technique  yields  better  results  and  is  much 
more  comfortable  for  surgeons  and  assistants,  who  at  one  time  were  obliged  to 
"wear  rubber  boots  or  have  wet  feet  at  every  operation.  Even  septic  wounds 
should  not  be  irrigated  with  strong  solutions,  because  they  are  unnecessary, 
harmful,  and  at  times  dangerous.  It  may  be  necessary  occasionally  to  wash 
•out  pus  cavities  when  they  are  too  deep  to  be  wiped  out  with  gauze,  and  in 
that  event  sterile  water  or  normal  salt  solution  should  be  used.  Some  surgeons 
irrigate  the  peritoneal  cavity  when  it  contains  pus  or  bowel  contents,  but  the 
majority  feel  that  it  is  better  to  wipe  out  with  gauze  than  to  take  tlie  risk  of 
washing  the  septic  material  into  new  territory.  A^^ien  irrigation  is  used  here 
it  should  be  with  sterile  normal  salt  solution  at  from  110°  to  118°  F.  In 
■operations  for  ectopic  pregnancy  after  rupture,  irrigation  with  salt  solution 
should  be  employed  after  the  bulk  of  the  blood  has  been  removed  with  hands 
and  gauze,  after  which  the  abdomen  should  be  left  full  of  the  solution. 

The  normal  or  'physiologic  salt  solution  is  so  called  because  it  corresponds  very 
closely  in  specific  gravity  to  the  blood.  It  is  prepared  by  dissolving  6  gm. 
(  oiss.)  of  sodium  chloride  in  each  litre  (  oxxxiiiss.)  of  water.  This  is  filtered 
and  sterilized  by  boiling  or  by  placing  in  flasks  in  a  steam  sterilizer,  and  kept  in 
sterile  bottles  plugged  with  cotton.  The  irrigator  should  be  made  of  glass  or  por- 
celain ware,  and  attached  to  a  stand  which  permits  of  elevating  or  lowering,  so 


GENERAL  SURGICAL  TREATMENT. 


705 


as  to  get  the  required  pressure.  To  the  h-rigator  is  attached  a  rubber  tube 
long  enough  to  carry  the  water  the  desired  distance.  At  the  end  of  the  rubber 
tubing  should  be  a  glass  nozzle,  which  can  be  changed  and  boiled.  A  rubber 
fountain  syringe  makes  a  good  irrigator  on  a  small  scale,  because  the  whole 
apparatus  can  be  boiled.  For  the  abdominal  cavity  a  pitcher  is  often  better 
than  an  irrigator,  and  especially  is  this  true  when  time  is  precious.  (See  Fig.  273.) 


Fig.  a. — Irrigator-Stands.     The  one  to  the  right  is  adjustable. 


In  performing  plastic  operations  irrigation  can  be  employed  to  great  advan- 
tage, a  warm  normal  salt  solution  being  used  in  lieu  of  sponges  to  keep  the  parts 
free  from  blood,  so  that  the  operator  can  see  what  he  is  doing. 

Chemical  disinfectants  still  play  a  part,  although  a  minor  one,  in  skin  disin- 
fection. An  ideal  chemical  disinfectant  for  the  skin  is  yet  to  be  found.  Those 
of  sufficient  strength  to  destroj'  bacteria  quickly  are  too  irritating  or  too  dan- 
gerous to  use  in  strong  solution,  and  dilute  solutions  act  too  slowly  to  be  of  great 
practical  value.  It  is  the  custom  of  most  surgeons  to  use  a  chemical  solution 
after  the  mechanical  cleansing  is  complete,  although  there  are  surgeons  whose 
sensitive  hands  will  not  permit  the  use  of  chemicals,  but  who,  nevertheless,  are 
able  to  secure  aseptic  woimds  after  mechanical  disinfection  alone.    Elaborate 


706  AMERICAN   PRACTICE  OF  SURGERY. 

irrigating  apparatus  containing  a  variety  of  chemical  solutions  is  not  much  in 
evidence  now.  A  chemical  solution  should  never  be  put  into  a  presumably- 
sterile  wound. 

Bichloride  of  mercury  holds  first  place  in  America  as  a  chemical  disinfectant, 
and  is  commonly  used,  in  aqueous  solution  of  an  average  strength  of  1  to  2,000, 
in  preparing  hands  and  skin.  This  drug  has  no  penetrating  power;  hence  its  ac- 
tion is  limited  to  the  surface,  where  it  will  kill  pyogenic  bacteria  if  brought  in 
contact  with  them  long  enough.  Harrington  has  shown  that  it  requires  a  ten- 
minutes'  exposure  of  a  1-to- 1,000  bichloride  solution  to  kill  the  Staphylococcus 
albus,  and  that  weaker  solutions  require  a  proportionately  longer  time.  The 
natural  inference  is  that,  from  the  bacteriologist's  standpoint,  our  bichloride 
solution  as  ordinarily  used  is  of  little  or  no  value.  From  the  surgeon's  stand- 
point, however,  the  fact  remains  that  better  results  have  been  secured  when  the 
solution  has  been  used  than  by  scrubbing  alone.  The  advantages  of  this  chem- 
ical are :  that  it  is  the  most  powerful  bactericide  at  our  command  and  that  it  is 
freely  soluble  in  water  and  alcohol.  The  disadvantages  are :  that  it  is  so  highly 
poisonous  and  irritating  that  strong  enough  solutions  cannot  be  used  to  destroy 
bacteria  within  a  reasonable  period  of  time ;  that  it  forms  an  insoluble,  inert 
albuminate;  and  that  it  corrodes  instruments  very  quickly.  Notwithstanding 
these  serious  objections,  its  popularity  is  well  deserved,  because  the  skin  is 
more  frequently  sterile  when  scrubbing  with  soap  and  water  is  followed  by 
scrubbing  in  a  bichloride  solution  than  when  the  latter  is  not  used.  It  kills 
many  germs,  inhibits  others,  and  buries  many  under  an  impenetrable  layer  of 
albuminates,  thus  rendering  them  harmless.  An  alcoholic  solution  acts  more 
powerfully  than  an  aqueous  one.  Fuerbringer's  method  of  skin  sterilization  is 
one  of  the  best  and  most  popular.  After  a  thorough  scrubbing  with  soap,  brush, 
and  hot  water,  he  next  scrubs  with  eighty-per-cent  alcohol  for  one  minute,  and 
finally  with  a  bichloride  solution.  After  a  long  series  of  experiments  Harring- 
ton found  that  a  solution  composed  of  commercial  alcohol  640  c.c,  hydrochloric 
acid  60  c.c,  water  300  c.c,  corrosive  sublimate  0.8  gm.,  killed  the  bacteria  in 
pus  from  a  carbuncle  in  less  than  thirty  seconds.  Hands  kept  in  this  solution 
for  two  minutes  were  usually  sterile.  This  solution  has  been  found  very  valu- 
able in  septic  cases  and  for  sterilization  of  hands  that  have  recently  been  ex- 
posed to  pus,  but,  unfortunately,  it  is  too  irritating  to  be  employed  as  a  rou- 
tine procedure. 

Carbolic  acid  was  the  agent  upon  which  Lister  placed  the  greatest  dependence 
in  his  early  work,  but  it  is  now  seldom  used  in  the  preparation  of  hands  or  skin, 
because  of  its  inferior  germicidal  powers,  its  poisonous  properties,  and  its  bad 
odor.  Of  late  years,  however,  it  has  come  into  very  general  use  in  sterilizing 
septic  wounds  and  cavities.  For  this  purpose  the  commercial  ninety-five-per- 
cent solution  is  used  in  its  full  strength.  Powell  taught  us  that  it  can  be  applied 
freely  in  this  strength  to  the  skin  or  a  wound  if  followed  within  two  minutes 


GENERAL   SURGICAL  TREATMENT.  707 

with  alcohol,  which  acts  as  an  antidote.  This  strong  acid  immediately  hardens 
the  tissues  so  that  they  cannot  absorb  it  quickly. .  A  much  weaker  solution  would 
be  dangerous,  because  it  would  not  harden  the  tissues.  A  septic  suppurating 
surface  or  sinus  can  be  so  thoroughly  prepared  by  using  the  pure  carbolic  acid  in 
this  way  that  an  aseptic  operation  may  be  performed  upon  the  part.  In  the 
case  of  old  bone  cavities  successful  results  can  be  obtained  by  clearing  out  the 
sequestra,  pus,  and  detritus,  and  then,  after  a  thorough  sterilization  with  the 
pure  carbolic  acid  and  alcohol,  filling  the  cavity  with  the  Mosetig-Moorhoff  bone 
paste  and  closing  the  wound  tight. 

Lysol  is  a  saponified  phenol  and  a  very  good  disinfectant  in  an  aqueous 
solution  of  a  strength  of  from  one  to  three  per  cent,  and  is  especially  well 
adapted  for  use  in  sterilizing  mucous  membranes.  It  is  smooth  and  pleasant 
to  the  touch,  but  has  a  disagreeable  odor,  which  will  remain  on  the  surgeon's 
hands  for  a  day. 

Potassium  Permanganate  and  Oxalic  Acid. — The  Schatz  method  has  been 
extensively  used  in  this  country,  notably  at  the  Johns  Hopkins  Hospital.  The 
hands  and  arms  are  first  scrubbed  for  ten  minutes  with  soap  and  hot  running 
water  or  many  changes  of  water.  They  are  next  immersed  for  two  minutes  in  a 
saturated  solution  of  potassium  permanganate,  after  which  they  are  washed  in 
a  warm  saturated  solution  of  oxalic  acid  until  the  color  disappears.  They  are 
then  washed  in  a  sterilized  lime  solution  to  remove  the  excess  of  oxalic  acid,  and, 
finally,  they  are  washed  in  sterilized  water.  Robb  recommends  that  after  this 
the  hands  be  washed  in  a  bichloride  solution ;  but  few  hands  will  stand  so  much 
and  so  many  chemicals,  and,  since  it  has  been  demonstrated  that  the  scrubbing  is 
the  essential  feature,  the  more  elaborate  method  seems  useless.  Kelly's  experi- 
ments showed  that  the  oxalic  acid  is  the  more  active  sterilizing  agent.  Harrington 
has  demonstrated  that  potassium  permanganate  is  a  very  feeble  germicide ;  that  it 
stains  the  skin  by  precipitating  a  lower  oxide,  oxygen  having  been  given  up  to 
the  epidermic  scales  and  other  organic  matter ;  but  that  as  soon  as  one  layer  of 
oxide  is  removed  by  dissolving  in  oxalic  acid,  other  layers,  indefinite  in  number, 
can  be  formed  by  a  reapplication  of  the  permanganate,  showing  that  the  oxidizing 
process  is  a  very  superficial  one.  He  concludes  that  "  a  dirty  hand  may  be  stained 
and  decolorized  as  well  as  a  clean  one,  but  the  dirt  remains.  Permanganate  re- 
moves no  dirt  and  destroys  only  weakly  resistant  bacteria."  It  would  seem, 
therefore,  that  the  real  virtue  in  the  Schatz  method  is  that  it  involves  a  great, 
deal  of  scrubbing,  which  might  as  well  be  done  without  the  chemicals. 

Iodine  is  a  prime  favorite  with  some  surgeons,  and  has  the  great  advantage 
of  being  comparatively  harmless.  A  solution  of  a  deep  sherry  color  is  recom- 
mended. The  iodine  method  of  sterilizing  catgut  is  the  most  common  and  one 
of  the  best. 

Alcohol  is  not  a  very  active  antiseptic,  but  is  a  very  valuable  accessory  in 
hand  and  skin  disinfection.    A  seventy-per-cent  solution  is  better  than  the  com- 


708  AMERICAN   PRACTICE   OF  SURGERY. 

mercial  alcohol.  It  helps  to  cleanse  the  skin  and  hardens  it.  Nothing  a  surgeon 
does  in  the  way  of  skin  sterilization  gives  him  such  a  sense  of  cleanliness  as  wash- 
ing in  alcohol,  and  this  is  doubtless  the  reason  why  it  is  so  popular.  Many 
surgeons  depend  on  mechanical  cleansing  followed  by  the  use  of  seventy-per- 
cent alcohol,  and  they  secure  as  good  results  as  are  secured  by  any  other  method. 

Ether  is  of  no  value  as  an  antiseptic,  but  acts  as  a  very  valuable  adjuvant  in 
skin  sterilization  by  dissolving  fat  and  dirt. 

Peroxide  of  hydrogen  has  very  little  value  as  an  antiseptic,  but  is  a  powerful 
oxidizer  and  is  very  helpful  in  cleansing  suppurating  wounds  and  deep  sinuses. 
It  is  capable  of  doing  great  harm,  however,  when  injected  into  cavitieg_  to  which 
there  is  not  a  free  outlet,  for  it  is  very  liable  to  force  bacteria  and  toxic  materials 
deeper  into  the  tissues.  For  cleansing  an  infected  wound  it  can  be  used  pure  or 
with  the  addition  of  an  equal  amount  of  water.  When  used  too  frequently  it 
interferes  with  the  healing  of  the  wound.  When  injected  into  a  wound  it 
effervesces  and  acts  mechanically  by  dislodging  particles  of  dirt  and  necrotic 
tissue.    This  mechanical  action  probably  constitutes  its  greatest  virtue. 

Conclusions  Concerning  Hand  Sterilization. 

Systematic  scrubbing  with  green  soap,  running  hot  water,  and  brush  for  ten 
minutes,  followed  by  the  use  of  a  l-to-2,000  bichloride  solution  or  seventy-per- 
cent alcohol,  or  both,  will  yield  as  good  or  better  results  than  are  obtainable  by 
any  other  method.  When  hands  have  recently  been  in  or  about  a  septic 
wound,  Harrington's  solution  should  be  used. 

Conclusions  Concerning  Skin  Sterilization. 

The  danger  of  infection  from  the  patient's  skin  is  much  less  than  that  from 
the  surgeon's  hands.  When  practicable,  the  seat  of  operation  should  be  shaved 
and  scrubbed  the  day  before  the  operation,  although  this  is  not  imperative.  The 
scrubbing  should  be  followed  by  the  application  of  ether  and  seventy-per-cent 
alcohol.  A  sterile  dressing  should  then  be  applied.  Just  before  the  operation 
the  skin  should  be  rescrubbed  with  soap  and  gauze,  washed  with  ether,  and 
finally  with  seventy-per-cent  alcohol  or  a  bichloride  solution,  or  both.  These 
methods  are  quite  universally  adopted  and  will  yield  as  good  results  as  any. 

Disinfection  of  mucous  membranes  is  somewhat  more  difficult  than  skin  dis- 
infection, and,  on  account  of  their  great  liability  to  be  absorbed,  chemicals  can- 
not be  very  freely  used.  The  vagina  should  be  scrubbed  and  irrigated  with  a 
three-per-cent  lysol  solution  some  time  before  the  operation,  and  just  before  the 
operation  it  should  be  scrubbed  for  five  minutes  with  green  soap  and  gauze,  fol- 
lowed by  an  application  of  lysol.  Bichloride  should  not  be  used.  The  rectum 
should  be  prepared  in  the  same  manner,  the  bowels  having  been  thoroughly 
emptied  the  day  before. 


GENERAL   SURGICAL   TREATMENT.  709 

Rubber  gloves  are  now  in  quite  general  use  in  America,  where  they  were 
first  introduced  by  Halsted.  The  objections  to  them  are,  that  they  are  somewhat 
expensive  and  that  they  interfere  with  the  surgeon's  tactile  sense  and  dexterity. 
The  first  objection  should  be  given  no  consideration,  since  rubber  gloves  have 
undoubtedly  saved  many  lives.  The  surgeon  soon  becomes  accustomed  to  their 
use,  so  that  he  can  work  almost  as  speedily  with  as  without  them.  They  do  delay 
the  operation  somewhat  by  slipping  when  the  tissues  are  handled  and. in  tying 
knots,  but  this  loss  is  compensated  for  many  times  over  by  the  additional  safety 
they  afford.  Mortality  rates  have  been  reduced  since  the  introduction  of  gloves 
far  more  than  can  be  accounted  for  without  taking  gloves  into  consideration. 
This  is  particularly  true  among  beginners  and  occasional  operators.  Every  sur- 
geon must  be  at  one  time  a  beginner,  and  occasional  operators  are  a  necessary 
evil.  A  thorough-going  surgeon  can  get  along  without  gloves,  and  many  of  them 
do,  because  they  know  how  to  prepare  and  protect  their  hands ;  but  every  as- 
sistant and  nurse  who  has  aught  to  do  with  the  wound,  instruments,  ligatures, 
or  dressings,  should  be  compelled  to  wear  them.  The  one  argument  in  their  favor 
which  overcomes  all  possible  objections,  is  that  they  can  be  made  absolutely 
sterile  and  are  therefore  unquestionably  helpful  in  maintaining  asepsis.  It  is  an 
economy  to  use  only  the  best  quality  of  seamless  gloves  made,  because  they  are 
more  pliable,  more  secure,  and  last  longer.  The  heavier  weight  is  preferable  for 
much  the  same  reasons,  and  the  surgeon  soon  becomes  so  accustomed  to  them 
that  he  does  not  notice  the  difference.  The  wearing  of  great,  clumsy  rubber 
gloves  full  of  holes,  and  of  cotton  gloves,  is  objectionable  because  they  do 
not  fully  protect  the  wound.  Gloves  should  fit  so  closely  so  that  they  will 
not  wrinkle,  but  not  so  closely  as  to  be  difficult  to  put  on  or  to  constrict 
the  hand  when  on.  After  an  operation  the  surgeon  should  wash  all  the  blood 
from  his  gloves  before  removing  them,  because  when  it  once  dries  on  them  it 
is  very  difficult  to  remove,  and,  when  not  removed,  may  become  a  source  of 
infection.  After  this  they  should  be  boiled  for  five  minutes,  and  if  not  required 
for  immediate  use  they  should  be  wrapped  in  a  sterile  towel  and  laid  away. 
When  cared  for  in  this  manner  it  will  be  necessary  to  boil  them  for  only  five 
minutes  when  they  are  next  wanted.  When  not  cared  for  properly  they  will 
require  a  much  longer  boiling,  which  may  do  them  harm.  When  gloves  are 
not  to  be  used  for  some  time  they  should  be  dusted  inside  with  sterile  talc  pow- 
der to  prevent  them  from  sticking  together.  In  hospital  work  this  is  unneces- 
sary, provided  they  are  thoroughly  dry  when  put  away.  A  beginner  is  very 
liable  to  tear  his  gloves  when  putting  them  on  and  off,  but  one  soon  becomes 
so  expert  that  they  can  be  handled  quickly  and  safely.  After  they  have  been 
boiled  preparatory  to  an  operation,  they  should  be  placed  in  a  basin  containing 
an  abundance  of  sterile  water.  The  surgeon  then  fills  the  glove  with  water, 
and  takes  firm  hold  of  the  upper  end  on  the  palmar  side  with  his  thumb  inside. 
He  then  gently  introduces  the  other  hand,  alternately  extending  and  flexing 


710  AilERICAX  PRACTICE  OF  SIIIGERY. 

the  thumb  and  little  finger  until  the  fingers  get  well  down  into  the  glove,  when 
the  latter  should  be  held  open  and  the  hand  gradually  closed,  thus  pressing 
out  all  the  surplus  water.  A  glove  should  not  be  adjusted  with  the  bare  hand, 
but  after  both  gloves  are  on  they  may  be  adjusted  at  will  without  fear  of  con- 
tamination. If  the  gloved  hands  are  then  dipped  in  a  bichloride  solution  the 
gloves  will  not  be  slippery.  It  Ls  ad-\'ised  by  some  that  a  bicliloride  solution 
be  used  instead  of  sterile  water  for  putting  the  gloves  on,  as  an  additional  anti- 
septic precaution;  but  since,  as  Harrington  has  demonstrated,  sweat  from  a 
sterilized  hand  is  aseptic,  this  is  umiecessar}'  and  the  solution  is  objectionable 
because  it  makes  it  more  difficult  to  put  the  gloves  on,  and  the  bichloride  blackens 
the  finger  nails.  An  elegant  way  to  put  on  gloves  is  with  a  h-sol  solution,  be- 
cause it  makes  them  smooth,  but  it  is  objectionable  on  account  of  its  disagree- 
able odor,  which  remains  with  the  siu-geon  all  da}'.  The  hands  must  be  as 
carefully  prepared  when  gloves  are  to  be  used  as  when  they  are  not,  for  the 
gloves  are  always  liable  to  be  torn,  and  then,  if  this  accident  should  happen 
at  a  time  when  the  enclosed  hand  had  not  been  adequately  sterilized,  the  patient 
would  be  exposed  to  a  corresponding  risk  of  infection.  Gloves  are  in  no  way  a 
substitute  for  hand  disinfection,  but  are  a  ver}-  valuable  additional  protection 
to  both  patient  and  surgeon.  Their  most  valuable  use,  however,  is  in  septic 
cases,  as  they  are  an  invaluable  protection  to  the  surgeon  at  the  time  and  of 
value  to  his  next  patient.  An  ungloved  hand  that  has  been  in  a  septic  wound 
cannot  be  made  safeh'  sterile  for  many  daj^s,  but  a  glove  so  used  can  be  made 
absolutely  sterile  by  a  few  minutes'  boiling.  The  surgeon  and  assistants  should 
always  wear  gloves  when  dressing  septic  wounds  or  when  examining  septic 
cases.  They  are  of  incalculable  ysdue  in  handling  specific  cases  with  open 
sores.  If  the  full  list  of  physicians  and  sm-geons  who  are  annually  infected 
with  S3'philis  for  need  of  this  simple  precaution  were  known,  it  would  be  star- 
tling. Small  punctures  in  gloves  may  be  closed  by  a  rubber  cement  made  for 
the  purpose.  Larger  tears  may  be  patched  with  pieces  of  discarded  gloves 
by  the  aid  of  heat.  A  torn  glove  finger  can  be  stretched  over  a  test  tube,  a 
piece  of  rubber  from  an  old  glove  laid  over  the  tear,  and  then,  by  running  a 
hot  Paquelin  cautery  around  the  edge  of  the  patch,  the  rubber  -will  be  made  to 
adhere  perfectly. 

Sterilization  by  He.^t. 

Heat  is  our  most  reliable  sterilizing  agent,  and  is  applied  by  means  of  the 
actual  cautery,  hot  air,  hot  water,  and  steam. 

The  actual  cautery  has  a  very  limited  application  as  a  sterilizing  agent,  but 
is  occasionally  resorted  to  when  a  very  A-irulent  local  infection  exists  or  is  sus- 
pected. It  is  very  efficient,  but  the  fact  that  it  destroys  the  tissues  limits  its 
usefulness.  The  same  objection  unfortunately  applies  to  all  forms  of  heat 
when  applied  to  tissues. 


GENERAL  SURGICAL  TREATMENT. 


711 


Hot  air  or  dry  heat  is  very  little  used  as  a  sterilizing  agent  because  hot  water 
or  steam  is  used  instead  for  almost  every  purpose  for  which  heat  is  applicable, 
and  its  penetrating  power  is  much  greater.  Dry  heat  is  used  in  the  Boeckmann 
process  of  catgut  sterilization  with  great  satisfaction.  Aside  from  this,  the 
chief  use  made  of  hot  air  is  in  drying  dressings  and  clothing  after  thej^  have 
been  sterilized  by  steam. 

Hot  water  is  a  very  efficient  sterilizing  agent  and  is  almost  universally  used 
in  the  sterilization  of  instruments,  unabsorbable  sutures,  and  gloves.  When 
facilities  for  steam  sterilization  are  not  at  hand,  utensils  and  dressings  may 
be  sterilized  bj'  boiling  in  water. 

Sterilization  of  Ixstrumexts. 

Boiling  in  water  is  the  best  agent  available  for  the  sterilization  of  instru- 
ments. Cutting  instruments,  knives,  scissors,  and  needles,  however,  are  dulled 
by  boiling.  When  they  haA^e  been  washed  they  should  be  placed  in  ninety-five- 
per-cent  carbolic  acid  for  ten  minutes,  after  which  they  should  be  kept  in  ster- 
ile water  or  alcohol  during  an  operation.     A  square  glass  or  porcelain  dish 


Fig.  274. — Instrument  Sterilizer;  equipped  with  one  large  and  two  small  trays. 


712  AMERICAN  PRACTICE  OF  SURGERY. 

should  be  kept  for  this  purpose;  it  should  be  long  enough  to  receive  cutting 
instruments,  of  such  a  depth  that  the  instruments  are  entirely  covered  by 
the  acid,  and  provided  at  one  corner  with  a  spout  tlirough  which  the  acid  can 
be  retm'ned  to  the  bottle  in  which  it  is  kept.  When  these  instruments  are 
cleaned  and  washed,  after  an  operation,  the  ten  minutes'  immersion  will  render 
them  absolutely  sterile  and  will  not  dull  them.  The  other  instruments  should 
be  boiled  for  ten  minutes.  Longer  boiling  is  unnecessary,  provided  the 
instruments  have  been  properly  washed  and  scrubbed  after  the  last 
operation;  and,  besides,  prolonged  boiling  injm-es  them.  To  prevent  cor- 
roding, sufficient  sodium  carbonate — common  soda — is  employed  to  make 
a  one-per-cent  solution — which  may  be  roughly  estimated  at  one  tablespoonful 
to  a  quart.  No  sterilizing  plant  is  complete  without  a  separate  instrument- 
boiler,  which  may  be  heated  in  the  same  manner  as  the  other  sterilizers  (Fig. 
274) .  It  is  made  with  a  wire  basket  inside,  which  enables  one  to  lift  at  once  all 
the  instruments  out  of  the  water.  Silk,  silkworm  gut,  horsehair,  nails,  pins, 
etc.,  are  usually  sterilized  in  the  instrument-boiler,  either  with  the  instruments 
or  separately.  Gloves  are  sterilized  in  the  same  apparatus,  but  should  be 
boiled  separately. 

Sterilization  of  Water. 

The  difference  between  ordinary  and  surgical  cleanliness  is  well  illustrated 
by  the  fact  that  water,  which  is  the  general  cleansing  agent  in  personal  cleanli- 
ness, is  utterly  unfit  for  surgical  purposes  until  it  has  been  sterilized.  It  can  be 
made  sterile  by  adding  chemicals,  but  they  are  objectionable  and  even  danger- 
ous. Water  can  be  made  sterile  by  boiling,  but  it  should  be  filtered  as  well, 
because  ordinary  water,  even  Avhen  sterilized  by  boiling,  contains  foreign  matter 
which,  in  a  wound,  is  objectionable.  In  an  emergency,  water  can  be  boiled 
in  an  open  wash-boiler,  from  which  it  may  be  dipped  with  a  sterilized  utensil, 
but  this  method  affords  an  opportunity  for  air  and  contact  infections.  Some 
one  may  put  a  dirty  hand  into  it  to  test  the  temperature,  and  the  dipper  or 
other  utensil  used  is  apt  to  be  laid  on  a  chair,  or  to  be  dropped  into  the  boiler 
after  it  has  been  handled  with  unsterilized  hands.  The  boiled  water  from  any 
steam  boiler  is  sterile  and  can  be  used  for  sterilizing  the  hands  as  it  comes  from 
the  faucet,  but  it  contains  foreign  matter,  and  is  therefore  not  suitable  for 
use  in  or  about  a  wound.  Every  hospital  should  have  special  apparatus  in 
which  water  can  be  filtered  and  sterilized  daily  for  use  in  the  operating-room. 
Water-sterilizing  outfits,  consisting  of  two  reservoirs,  one  for  hot  and  one  for 
cold  water,  with  a  filtering  attachment,  are  now  manufactured  and  answer 
the  recjuired  purposes  admirably.  They  are  arranged  for  using  oil,  gas,  or 
steam  (Fig.  275).  With  a  high-pressure  outfit,  boiling  for  twenty  minutes  with 
a  pressure  of  fifteen  pounds  is  sufficient,  for  with  this  pressure  the  tempera- 
ture is  250°  F.,  which  in  that  time  will  destroy  all  manner  of  germs.     With  a 


GENERAL  SURGICAL  TREATMENT.  713 

low-pressure  outfit  the  boiling  should  continue  for  at  least  twice  as  long  a  time 
because  the  temperature  is  only  212°  F.  The-  coki-water  tank  is  so  arranged 
that  the  water  can  be  cooled  very  quicldy.  The  outlet  faucets  when  not  in 
use  should  be  ^Tapped  in  gauze  to  keep  off  the  dust. 


Fig.   275. — Water  Sterilizers  Arranged  for  Heating  by  High-Pressure  Steam. 


Steriliz.\tion  of  Dressings. 

The  whole  scheme  of  sterilization  is  based  upon  the  imderlying  principles 
first  discovered  by  Pasteur  and  first  practically  applied  by  Lister.  Anything 
that  will  destroy  bacteria  will  sterilize  dressings.  At  first,  Lister  depended 
upon  chemicals  almost  exclusively,  but  the  objections  were  found  to  be  so 
manifold  that  they  have  given  place  to  heat  in  the  form  of  steam  almost  alto- 
gether. For  a  time  manufacturers  were  kept  busy  manufacturing  the  various 
medicated  gauzes,  but  now^,  aside  from  iodoform  gauze,  which  is  used  in  a 
special  class  of  cases,  they  are  not  in  the  market,  because  plain  sterile  gauze 
has  taken  their  place.  Sterile  gauze  may  be  bought  in  sealed  packages  which 
are  very  convenient  for  those  who   use  it  in  small  quantities.     For  aseptic 


714  AMERICAX   PRACTICE   OF   SURGERY. 

cases  the  small  packages  should  be  used,  because  when  a  package  is  once  opened 
for  a  dressing  it  should  not  be  depended  upon  for  later  dressings  on  account 
of  the  many  possibilities  of  its  becoming  infected.  It  is  safer  and  more  econom- 
ical, however,  for  ever}'  practitioner  who  does  surgical  work  to  have  his  ovm 
sterilizer.     Low-pressure   sterilizers  of  small  size,  arranged  for  oil  or  gas,  can 


riG.  276. Dressing  Sterilizer,  Instrument  Sterilizer,  and  Water  Sterilizer  Combined;  for  office  use. 

(Scanlan-Morris  Co..  Madison,  Wis.) 


be 'bought  cheaply  and  are  efhcient.  The  best  sterilizing  chambers  for  both 
water  and  dressings  are  made  of  heavy  copper  and  should  be  nickel-plated 
because  otherwise  the  heat  discolors  the  copper  (Fig.  276).  There  are  two  dif- 
ferent varieties  of  steam  sterilizers  employed,  the  high-pressure  and  the  low- 
pressure.  The  high-pressure  apparatus  (Fig.  277)  is  so  arranged  that  a,  press- 
ure of  from  ten  to  fifteen  pounds  to  the  square  inch  can  be  gained  ^'ery  quickly 


GENERAL   SURGICAL  TREATMENT. 


715 


and  maintained  indefinitely  at  a  temperature  of  from  240°  to  250°  F.  This 
high-pressure  steam  is  the  most  penetratmg  and  has  the  greatest  bactericidal 
action.  This  variet}^  of  apparatus  is  arranged  for  heating  by  steam  from  the 
ordinary  boilers  of  a  building,  or  by  means  of  gas-burners,  and  is  the  variety 
commonly  used  in  large  hospitals.  When  boiler  steam  is  used  as  a  heating 
medium  it  should  be  of  not  less  than  thirty-five  pomids  pressure.  In  smaller 
institutions  where  a  low-pressure  engine  is  used  or  where  the  house  plant  is 
not  used  at  all  times,  a  small  boiler  especially  for  the  sterilizing  outfit  can  be 


Showing  Front  View. 


Showi 


Fig.  277. — The  Knj'-Scheerer  Dressing  Sterilizer  (1903  Model). 

A,  Gauge  to  register  press-ure  within  chamber;  B,  gauge  to  register  pressure  within  jacket:  C,  pan 
to  catch  any  condensation  from  chamber;  D,  ventilating  pipe  for  gas  combustion;  E,  handle  for 
opening  or  closing  door. 

1,  Valve  for  the  discharge  of  air  displaced  by  water;  2,  -vah-e  and  funnel  for  filling  jacket  with 
water;  3,  valve  for  injecting  water  into  jacket;  4,  valve  connecting  air  ejector  to  chamber;  5,  valve 
tor  controlling  steam  for  vacuum  apparatus;  6,  valve  for  admitting  steam  from  jacket  to  chamber; 
7,  valve  for  withdrawing  any  condensation  from  chamber;  8,  gas  attachment ;  9,  ejector  or  vacuum 
apparatus;   10,  air  filter  tor  destroying  vacuum;   11,  valve  to  empty  water  from  jacket. 


716 


AMERICAN  PRACTICE  OF  SURGERY. 


used  convenient!}^  and  economically.  High-pressure  steam  is  efficient.  The 
objections  to  it  are  that  it  is  expensive  and  requires  skill  to  handle  it  properly. 
A  very  essential  part  of  this  apparatus  is  the  vacuum  or  air-exliaust  attachment 
by  means  of  which  the  air  is  withdrawn  from  the  sterilizing  chamber  before 
steam  is  turned  in.  Without  this  feature  the  temperature  will  vary  in  different 
parts  of  the  chamber  and  the  degree  of  temperature  attained  will  be  uncertain. 
Unskilled  persons  are  liable  to  turn  the  steam  into  the  sterilizing  chamber 


Fig.  278. — Large  Hospital  Sterilizer  with  Steam  Coils. 


without  having  emptied  it  of  air,  and  the  result  is  that  the  dressings  are  not 
sterilized. 

The  low-pressure  sterilizers  are  the  ones  commonly  employed  in  physicians' 
offices  and  in  small  hospitals,  and  are  popular  in  large  hospitals  in  the  West 
(Fig.  278).  When  properly  constructed  they  are  efficient  and  more  economical 
than  the  high-pressure  sterilizers;  furthermore,  they  require  no  special  skill 
to  operate  (Fig.  279).  The  introduction  of  the  steam  from  above  is  an  essen- 
tial feature  of  the  low-pressure  sterilizer,  for  in  this  way  the  air  is  thoroughly 
driven  out.     The  live  or  moving  steam  coming  up  through  a  jacket  outside 


GENERAL  SURGICAL  TREATMENT. 


717 


of  the  dressings  equalizes  the  temperature  and  prevents  condensation.  Before 
the  steam  is  turned  into  the  dressings  they  should  be  thoroughly  heated  by 
running  the  hot-air  current  through  them.  Either  oil,  gas,  or  steam  can  be 
used  as  a  means  of  generating  the  heat  for  these  sterilizers.  "Wlien  the  low- 
pressure  system  is  used  the  dressings  should  be  steamed  for  one  hour.  Frac- 
tional sterilization  of  dressings  is  imnecessary,  but  it  is  customary  in  most 
hospitals  to  sterilize  them  the  evening  before  and  again  in  the  morning  of  the 
day  on  which  the  operation  is  to  take  place.  Cotton,  gauze,  towels,  caps, 
gowns,  etc.,  can  be  loosely  rolled  in  cotton  cloths  kept  for  the  purpose  before 


Fig.  279. — Diagram  showing  Cross-Section  of  the  Large  Sterilizer  Represented  in  the  Previous  Figure. 
Steam  is  generated  in  boiler  (A)  and  ascends  from  the  boiler  through  double  walls  to  the  top  of  the  steril- 
izing chamber,  where  it  is  held  in  suspension  by  the  cover  (C)  ;  tlien  by  its  own  pressure  it  is  forced  down 
through  the  dressings,  excluding  all  the  air  from  the  sterilizing  chamber.  At  the  point  (E)  it  finds  an 
escape  and  is  dissipated  by  hot  air  from  tlie  burner,  which  is  placed  below.  After  the  process  of  steril- 
ization is  completed,  valve  (L)  is  thrown  open  and  the  steam  in  the  boiler  passes  up  through  the  double 
walls  and  out  through  this  valve.  The  steam  in  the  sterilizing  chamber  is  driven  out  by  the  hot  air 
coming  in  from  the  burner  below.  The  hot  air  circulating  up  through  the  dressings  thoroughly  dries 
them  out  so  that  they  may  be  taken  out  hot  and  dry  ready  for  application. 

The  following  is  a  list  of  the  parts  of  the  Scanlan  sterilizer: 

(C)  Lid,  (A^)  valve  lid,  (KK)  water-tight  joint  for  lid.  (BB)  sterilizing  chamber,  (D)  wire  traj'  to  sup- 
port dressings,  (E  and  F)  shields  to  protect  the  dressings  from  being  bvirned,  (.-1.1)  boiler  for  water,  (/) 
point  for  filling  boiler. 


being  placed  in  the  sterilizer.  They  must  not  be  roUetl  or  packed  too  tightly, 
for  this  prevents  the  steam  from  penetrating  them.  Tight  packing  in  too 
small  a  sterilizer  is  a  common  error  in  sterilization.  Utensils  for  the  operating- 
room — basins,  pitchers,  etc. — can  be  sterilized  in  the  same  chamber  used  for 
the  dressings,  but  it  is  a  great  convenience  in  hospitals  to  have  a  separate  uten- 
sil sterilizer  (Fig.  280). 


718 


AMERICAN  PRACTICE  OF  SURGERY. 


SURGICAL  DRESSINGS  AND    SPONGES. 


The  most  remarkable  feature  of  modern  surgical  dressings  is  the  simplicity 
of  the  dressings  and  sponges.  Before  the  Listerian  era  all  manner  of  substances 
such  as  jute,  bran,  and  sawdust  were  employed  with  what  would  now  be  con- 
sidered unsatisfactory  results.  Lint  made  from 
Imen  or  flax  was  the  most  popular.  The  War 
of  the  Rebellion  is  sometimes  spoken  of  as  the 
era  of  "wet-rag  surgery,"  because  the  dressing 
commonly  used  then  was  a  cloth  wet  in  cold 
water.  Not  long  after  the  close  of  the  war 
many  surgeons  trietl  the  treating  of  wouirds 
without  dressings.  A  great  variety  of  neces- 
sarily infected  ointments  held  high  place  in 
surgerj^,  and  were  favorites  among  the  laity. 
They  were  usuall}'  spread  on  cloth  or  surgeon's 
lint,  made  for  the  purpose.  With  our  present 
knowledge  of  infection  and  its  dangers  we  often 
wonder  how  wounds  ever  healed  so  soon,  sub- 
jected as  they  were  to  so  many  sources  of  in- 
fection. In  antiseptic  technique  as  taught  by 
Lister  the  dressings  were  elaborate  and  com- 
plicated, and  were  impregnated  with  chem- 
icals. Their  use  was  based  upon  the  belief  that 
air  infection  was  a  great  danger  during  and  after 
the  operation,  but  since  it  has  been  demon- 
strated that  this  is  one  of  the  least  of  the  dangers  the  dressings  have 
assumed  their  present  simple  form.  Then  the  chemicals  in  the  dressings 
often  irritated  the  patient,  but  now  our  experience  demonstrates  that  they  are 
entirely  uimecessary.  The  requisites  of  a  surgical  dressing  are  that  they  shall 
be  sterile,  dry,  and  comfortable.  The  materials  needed  for  the  dressing  of  an 
aseptic  wound  are  the  coarse,  loosely  woven  cotton  cloth  manufactured  for  the 
purpose  and  known  as  gauze,  specially  prepared  cotton  known  as  absorbent 
cotton,  and  a  cotton  roller  bandage. 

Gauze  is  applied  next  to  the  wound  and  must  be  sterile  so  that  it  will  not 
cause  infection.  It  must  be  dry  and  loosely  woven  so  that  it  will  keep  the 
wound  dry  by  quickly  absorbing  moisture  that  may  come  from  the  wound. 
Moisture  is  necessary  for  the  development  of  bacteria,  and  a  dressing  which 
will  keep  the  wound  dry  prevents  their  growth,  where  a  moist  one  would  en- 
courage it.  The  absorbent  cotton  should  be  applied  outside  the  gauze  for 
protection  and  comfort.  It  prevents  the  germs  from  gaining  access  to  the 
woimd,  and  b_v  its  bulk  and  softness  protects  the  wound  from  injvuy.     Absorb- 


FiG.  2S0. — Large  Hospital  Utensil 
Sterilizer,  for  use  in  Sterilizing  Wash 
Basins,  Pus  Basins,  Trays,  etc. — 
(From  Scanlan-Morris  Co.,  Madison, 
Wis.) 


GENERAL  SURGICAL  TREATMENT.  719 

ent  cotton  is  used  in  bacteriologic  laboratories  to  protect  culture  media  from 
air  infection.  The  bandage  is  applied  over  dressings  to  keep  them  in  place. 
The  gauze  may  be  cut  into  squares  of  various  sizes,  according  to  the  dimensions 
and  location  of  the  wound,  or  it  may  be  cut  in  long  strips  of  various  widths, 
and  loosely  rolled  up.  These  various-sized  pieces  of  gauze  should  be  made' 
into  bimdles  of  moderate  dimensions  and  each  bundle  ^Tapped  and  puined 
loosely  in  a  cotton  cloth  ready  for  sterilization.  They  are  then  piled  loosely 
— not  packed — in  the  sterilizing  chambers  and  sterilized  by  steam,  followed, 
by  dry  hot  air.  ^Vllen  removed  from  the  sterilizer  the  packages  should  be- 
laid on  tables  covered  with  sterile  towels.  The  wrappers  should  not  be  re- 
moved imtil  the  gauze  is  about  to  be  used.  The  wrapper  is  sufficient  protec- 
tion against  contamination  for  a  short  time,  and,  when  it  is  removed,  should 
be  considered  septic  and  not  allowed  to  touch  the  gauze  again  because  it  has 
been  handled  and  perhaps  otherwise  infected.  Surgeons'  gauze  can  be  pur- 
chased by  the  yard  or  the  bolt  from  instrument  houses  or  dry-goods  houses.  In 
an  emergency  the  common  cheese  cloth  may  be  used,  but  it  is  too  closely 
woven  and  too  hard  for  general  use. 

Cotton  in  its  natural  state  is  imfit  for  surgical  dressings  because  it  contains 
an  oily  substance  which  prevents  it  from  absorbing  licjuids,  but,  with  the  devel- 
opment of  antiseptic  and  aseptic  technique,  manufacturers  have  prepared  it 
so  that  it  has  entirely  supplanted  linen  as  a  surgical  dressing.  At  the  present 
time  cotton  fibre  is  in  such  great  demand  for  surgical  purposes  that  its  prepara- 
tion has  become  a  great  industry.  The  best  quality  of  surgical  cotton,  or 
absorbent  cotton,  comes  from  the  factory  in  long  strips  rolled  between  layers 
of  tissue  paper.  When  dropped  into  water  it  will  absorb  so  rapidly  that  it 
sinks  almost  immediately.  A  good  quality  will  absorb  as  high  as  fifteen  times 
its  own  weight  of  water.  Only  the  best  grade  should  be  used  in  surgery;  it 
is  manufactured  from  the  fresh  cotton  fibre,  while  the  cheaper  grades  are  made 
from  cotton  rags  taken  oft  times  from  filthy  surroundings.  Absorbent  cotton 
of  good  qualitj''  may  be  bought  at  most  drug  stores  in  packages  of  a  size  to  suit 
the  purchaser.  Absorbent  cotton  must  be  cut  in  pieces  of  various  size,  wrapped 
in  cotton  cloth  covers,  as  gauze  is  prepared  for  sterilization,  and  then  sterilized 
by  steam,  followed  by  hot  air.  The  processes  of  preparation  do  not  sterilize 
the  cotton  and  it  should  not  be  used  on  an  aseptic  woimd  without  having  been 
sterilized  by  steam. 

Gauze  bandages  have  almost  entirely  supplanted  bandages  made  from  heav- 
ier cotton  cloth.  They  are  made  from  a  closer  woven  gauze  than  that  used 
for  dressings;  this  gauze,  however,  is  light  and  elastic.  The  manufacturers 
sterilize  them  and  their  paper  wrapping,  thus  rendering  them  fit  to  be  applied 
outside  the  gauze  and  cotton  without  resterilizing.  The  use  of  these  elastic 
bandages  over  liberal  layers  of  gauze  and  cotton  has  practically  eliminated 
the  danger  of  tight  bandaging. 


720  AMERICAN  PRACTICE  OF  SURGERY. 

Sponges  are  no  longer  used  in  surgery,  but  they  were  for  a  long  time  considered 
an  essential  part  of  surgical  technique.  The  name  sponge  is  often  applied  to 
the  gauze  pads  now  employed,  and  the  use  of  them  is  termed  sponging  by  some. 
Gauze  pads  are  not  so  soft  and  elegant  as  marine  sponges,  but  the  former 
can  be  made  sterile  by  steam,  while  the  latter  do  not  bear  heat  well  in  any  form, 
and  all  methods  of  sterilizing  them  have  proved  disappointing.  The  pads, 
or  "sponges,"  for  use  during  the  operation  are  made  from  the  same  gauze  as 
that  used  for  dressings  and  are  sterilized  in  the  same  manner.  The  gauze  is 
cut  in  pieces  about  six  or  eight  inches  square  and  folded  so  as  to  turn  all  rough 
edges  in  and  make  a  pad  three  or  iour  inches  square  and  four  layers,,,  thick.  All 
ravellings  must  be  inside  so  as  to  prevent  them  from  being  left  in  the  wound 
where  they  may  act  as  foreign  bodies.  Each  pad  is  used  but  once  and  then 
thrown  away.  Pads  liave  two  important  advantages  over  sponges:  first,  they 
can  be  made  sterile;  and  second,  they  are  inexpensive  and  therefore  need  not 
be  used  but  once.  For  abdominal  work  large  gauze  pads  are  made  for  pro- 
tecting the  bowels  and  keeping  them  out  of  the  operator's  way.  These  pads 
may  have  tapes  attached  to  them  to  which  forceps  can  be  fastened  to  prevent 
the  pads  from  being  left  in  the  abdomen.  This  is  unnecessary,  however,  where 
the  operating-room  force  is  trained  to  keep  careful  count  of  the  number  used 
and  to  see  that  all  are  accounted  for  before  closing  up  the  wound.  The 
small  pads  are  better  when  used  dry,  but  the  large  ones  which  are  left  in  con- 
tact with  the  peritoneum  for  some  time  should  be  wrung  out  of  a  warm  normal 
salt  solution  just  before  using,  to  prevent  them  from  adhering  to  and  injuring 
the  peritoneimi.  The  pads  must  be  thoroughh^  sterilized  before,  and  carefully 
protected  from  contamination  during,  the  operation,  because  they  come  in  direct 
■contact  with  the  wound. 

Towels,  preferably  of  cotton,  are  a  very  necessary  and  convenient  article 
for  use  during  an  operation.  They  should  be  of  medium  size — about  eighteen 
by  thu'ty-six  inches, — of  medium  weight  and  without  fringe.  This  material 
may  be  bought  by  the  bolt  and  cut  into  the  desired  lengths.  Since  they  are  to 
be  used  more  than  once,  they  should  be  very  carefully  washed  and  boiled  after 
each  operation,  and  thoroughly  sterilized  by  steam  just  before  the  operation. 
They  are  usually  sterilized  in  the  same  chamber  with  the  gauze.  They  should 
be  made  into  bundles,  not  too  large  nor  too  closely  packed,  and  should  be  cov- 
ered with  a  cotton-cloth  wrapper  just  as  the  gauze  is  prepared  for  sterilization, 
and  should  be  handled  and  protected  in  the  same  manner  after  removal  from 
the  sterilizer.  They  are  used  for  drying  the  hands  of  the  surgeon  and  assistants, 
and  for  covering  the  unsterilized  portions  of  the  patient's  body  to  prevent 
contamination  of  hands,  dressings,  instruments,  ligatures,  and  sutm'es.  Sheets 
of  larger  size,  made  of  heavy  cotton  sheeting  and  prepared  in  the  same  manner, 
may  be  conveniently  used  for  draping  the  patient,  but  towels  are  indispensable. 
The  towels  may  be  pinned  together  with  sterile  safety  pins  to  keep  them  in 


GENERAL  SURGICAL  TREATMENT. 


721 


place.  They  should  not  be  wet  in  a  bichloride  solution,  because  they  would 
then  corrode  the  instruments. 

Caps  made  of  cotton  or  linen  should  be  worn  by  the  surgeon  and  assistants 
to  prevent  infecting  agents  from  falling  from  the  head  into  the  wound.  They 
should  be  sterilized  and  cared  for  in  the 
same  manner  as  the  dressings.  The  sur- 
geon should  cover  his  beard  with  gauze. 
He  should  not  wear  nose  glasses,  es- 
pecially when  doing  abdominal  work,  as 
they  may  need  adjusting  during  the  opera- 
tion, and  they  have  been  known  to  drop 
into  the  abdomen.  Spectacles  are  better 
and  safer. 

Masks  are  not  worn  by  all  surgeons, 
but  most  careful  surgeons  wear  them. 
They  are  undoubtedl}'  an  additional  source 
of  protection,  and  when  the  surgeon  is 
obliged  to  talk  during  the  operation  he 
should  wear  a  mask,  for  it  is  impossible 
to  avoid  talking  into  the  wound  at  times; 
and  when  he  does,  droplets  of  saliva 
crowded  with  bacteria  are  bound  to  enter 
the  wound  unless  prevented  by  a  mask. 
The  mask  is  usually  made  from  a  piece 
of  sterile  gauze  which  is  tied  over  the  top 
of  the  head,  coming  down  over  the  nose 
and  mouth  (Fig.  281).  This  form  of  mask 
is  liable  to  come  off  or  to  become  dis- 
placed so  as  to  interfere  with  vision.      It 

is  better  to  attach  the  mask  to  the  cap  or  to  a  wire  frame  worn  like  a  pair 
of  spectacles.  The  mask  should  be  sterile,  and  to  that  end  should  be 
changed  often.     It  is  better  to  wear  no  mask  than  to  wear  a  soiled  one. 

Operating  gowns  are  almost  universally  worn  in  the  operating-room.  They 
may  be  made  of  hnen  or  cotton,  should  fit  loosely,  and  should  be  of  sufficient 
length  to  reach  the  wearer's  shoe  tops.  The  sleeves  may  be  long  or  short  accord- 
ing to  the  fancy  of  the  operator,  but  the  short  sleeve  which  fastens  just  above 
the  elbow  is  the  one  most  commonly  used.  The  long  sleeve  is  objectionable 
because  it  becomes  wet  and  disagreeable,  and  when  it  becomes  bloody  can- 
not be  changed  without  changing  the  whole  gown.  To  continue  to  wear  a 
gown  with  bloody  sleeves  is  very  like  using  a  sponge  many  times  over  and  it 
looks  very  untidy.  The  gowns  are  to  be  prepared  for  sterilizing  just  as  the 
dressings  and  towels  are,  each  gown  being  wrapped  separately  in  a  cotton  cloth 


-U-shaped  Operating  Mask,  on 
a  Spectacle  Frame. 


722  AMERICAN   PRACTICE   OF  SURGERY. 

and  then  sterilized  by  steam.  After  being  removed  from  the  sterihzer  they 
must  be  protected  as  carefully  as  the  dressings,  not  being  touched  by  unsterile 
hands.  A  nm-se  whose  hands  are  not  sterile  may  unpin  the  -WTapper  and  open 
it  so  that  the  gown  may  be  unfolded  and  put  on  by  sterile  hands.  After  the 
operation,  gowns  must  be  carefully  washed  and  boiled.  The  gown  is  for  the 
protection  of  the  wound  and  not  of  the  surgeon  or  his  clothing,  and  must  be 
as  carefully  sterilized  and  handled  as  the  dressings.  It  is  customary  for  sui- 
geons  and  assistants  to  wear  rubber-cloth  aprons  for  the  protection  of  their 
clothing.  These  aprons  should  be  put  on  before  the  hand-scrubbing  begins, 
but  the  gown  should  not  be  worn  until  just  before  the  operation. 

The  trained  nurse  is  the  one  to  whom  the  preparation  of  all  dressings  and 
suture  materials  is  entrusted,  and  it  is  therefore  very  necessary  that  she  be 
thoroughly  trained  in  the  principles  underlying  their  preparation.  No  matter 
how  honest  and  faithful  she  may  be,  if  she  is  merely  following  out  instructions 
without  understanding  the  principles  involved  she  is  certain  to  make  mistakes. 
The  trained  nurse  is  needed  in  aseptic  surgery.  She  is  often  trusted  more  than 
the  assistant,  because  a  very  important  part  of  her  work — the  preparation 
work — is  done  in  the  absence  of  the  surgeon,  and  if  she  were  to  fail  in  the  per- 
formance of  her  dut}'  the  surgeon  would  surely  fail  to  get  aseptic  wounds.  There 
is  a  tendency  at  the  present  time  to  overtrain  nurses.  An  overtrained  rmrse 
is  more  objectionable  than  an  undertrained  one  because  she  is  disposed  to  have 
opinions  concerning  matters  which  are  none  of  her  concern.  It  is  a  mistake 
to  teach  nurses  pathology,  diagnosis,  and  treatment,  because  at  best  they  can 
get  only  a  smattering  of  Icnowledge,  which  is  unnecessary,  always  annoying, 
and  often  dangerous.  The  well- trained  nm'se  is  the  one  upon  whom  we  aU 
depend  as  an  invaluable  assistant  and  adjunct,  but  we  do  not  need  her  as  a 
consultant.  It  is  WTong  for  the  surgeon  to  place  too  much  responsilDility  upon 
the  nurse  during  the  after-treatment.  He  himself  should  carry  that  to  the 
end.  Doctors  who  have  not  had  proper  training  and  who  undertake  to  do  sur- 
gery are  prone  to  blame  the  nurse  for  their  failure  in  asepsis,  but  the  average 
trained  nurse  is  a  much  safer  person  in  the  operating-room  than  a  poorly  trained 
doctor. 

Dusting  poicders,  at  one  time  considered  so  essential,  are  seldom  used  now 
save  from  force  of  habit.  They  have  little  or  no  value  as  disinfectants.  Their 
only  real  value  is  in  keeping  the  wound  dry,  and  this  can  be  done  much  better 
by  dry  sterile  gauze.  When  a  wound  is  dried  by  a  powder  it  forms  a  scab  and 
prevents  the  escape  of  discharges  instead  of  draining  them  away.  Bacteria 
often  thrive  when  surrounded  by  the  powders  in  use.  Aseptic  wounds  do  not 
need  powder,  and  their  value  in  septic  cases  is  questionable. 

Iodoform  at  one  time  was  so  universally  employed  in  wound  dressing  that  a 
surgeon  might  be  recognized  anywhere  by  the  disagreeable  odor.  The  extremes 
to  which  its  use  was  carried  are  being  followed  by  the  usual  reaction,  and  this 


GENERAL   SURGICAL   TREATMENT.  723 

drug  may  be  altogether  neglected  after  a  time,  regardless  of  its  merits.  Not 
many  would  think  of  dusting  a  fresh  wound  with  iodoform  now,  and  only  few 
use  it  in  septic  cases.  Bacteriologists  demonstrated  that  it  is  not  a  germicide 
and  that  it  is  necessary  to  sterilize  it  when  injected  into  cavities.  It  is  to  be 
noted,  however,  that  many  of  those  who  were  enthusiastic  in  its  use  seldom 
employ  it  no^\\  Iodoform  is  still  used  quite  extensively  in  the  form  of  an 
emulsion  and  of  iodoform  gauze,  but  even  they  do  not  occupy  the  high  place 
they  once  did.  They  are  used  most  frequently  in  local  tuberculoses  because 
of  the  supposed  inhibitory  action  of  iodoform  upon  the  tubercle  bacillus.  The 
Mosetig-Moorhoff  bone  plug,  so  lately  of  prominence,  contains  a  large  percent- 
age of  iodoform. 

The  iodoform  emulsion  commonly  used  consists  of  ten  per  cent  of  iodoform 
in  olive  oil.  This  has  been  given  a  very  extensive  trial  by  orthopedists  as  an 
injection  in  tuberculous  joint  disease,  but  has  been  practically  abandoned 
because  it  is  disappointing.  It  is  still  employed  in  injecting  cold  abscesses. 
The  abscess  is  first  emptied  through  a  small  incision  and  irrigated  with  a  normal 
salt  solution  which  acts  mechanicall}^,  forcing  out  the  detritus  often  found  in 
these  abscesses.  It  is  dangerous  and  unnecessary  to  irrigate  a  large  abscess 
of  this  kind  with  a  bichloride  solution.  In  making  the  incision  in  these  cases 
the  skin  should  be  drawn  to  one  side  so  that  it  and  the  deeper  tissues  are  opened 
at  different  points,  making  a  valve-like  opening.  The  emulsion  should  be 
warmed  and  thoroughly  shaken,  when  it  can  be  injected  into  the  cavity  by 
a  sterile  glass  or  hard-rubber  syringe.  Several  ounces  may  be  injected  with 
safety,  since  the  iodoform  will  be  absorbed  too  slowly  from  these  old  cavities 
to  be  poisonous.  The  wound  is  then  closed  tightly,  layer  by  layer,  the  deeper 
ones  with  catgut,  and  a  surgical  dressing  applied.  Good  results  will  follow 
in  the  majority  of  cases. 

Iodoform  gauze  is  used  more  frequently  now  than  any  other  medicated  gauze. 
It  is  used  for  packing  wounds  about  the  natural  orifices  of  the  body  because  of 
iodoform's  inhibitory  action  on  bacteria.  It  is  also  very  extensively  used  in 
packing  tuberculous  cavities  after  operation  both  in  bone  and  in  soft  tissues. 
It  should  never  be  introduced  into  the  abdominal  cavity,  as  the  peritoneum 
is  very  susceptible  to  the  irritating  and  poisonous  properties  of  iodoform.  Iodo- 
form gauze  is  rarely  used  as  a  flressing  for  fresh  wounds,  and  its  value  in  septic 
wounds  is  outweighed  by  its  irritating  properties  and  its  disagreeable  odor. 
It  is  believed  by  many  to  act  as  an  inhibitory  agent  in  suppwating  wounds  and 
is  very  commonly  used  as  a  drain  for  them,  but  it  does  not  stop  or  control  sup- 
puration, ^'arious  strengths  of  iodoform  gauze  are  prepared,  but  the  ten-per- 
cent gauze  will  answer  every  purpose  and  is  not  so  objectionable  as  a  stronger 
preparation.  Ten-per-cent  gauze  should  contain,  when  dry,  ten  per  cent  by 
weight  of  iodoform.  A  ready  method  for  preparing  the  gauze  in  small  quan- 
tities is  to  rub  the  pulverized  iodoform  into  sterile  gauze  which  has  been 


724  AMERICAN  PRACTICE  OF  SURGERY. 

slightly  moistened.  Manufacturers  and  large  hospitals  have  their  own  formulse 
for  preparing  it  on  a  large  scale.  The  following  is  a  fair  example  of  the  various 
methods:  "To  prepare  a  ten-per-cent  iodoform  gauze  take  fifty  parts  by  weight 
of  gauze,  forty  parts  of  glycerin,  and  ten  of  iodoform.  To  properly  incor- 
porate the  latter,  the  addition  of  two  hundred  parts  of  alcohol  and  one  hundred 
parts  of  water  is  required.  When  this  gauze  is  finished  and  dried  the  alco- 
hol and  water  will  have  evaporated,  while  the  glycerin  and  the  iodoform  re- 
main, and  the  latter  will  then  be  ten  per  cent." 

The  Yon  Mosetig-Moorhoff  hone  plug  is  the  iodoform  preparation  most 
recently  introduced,  and  its  use  has  certainly  a  very  great  advantage  over 
any  other  method  of  treating  bone  cavities.  After  our  experience  with  iodo- 
form in  other  dressings  we  are  naturally  somewhat  sceptical  regarding  its  vir- 
tues in  the  bone  plug,  JDut  the  fact  remains  that  the  bone  plug  containing  iodo- 
form answers  the  purpose  for  which  it  was  invented  better  than  any  other  ever 
used,  whether  mecUcatedorunmedicated.  The  correctness  of  the  principle  of  filling 
a  bone  cavity  with  an  artificial  filling  and  closing  the  wound  tight  is  established, 
but  whether  the  efficac}^  of  the  filling  is  due  to  the  iodoform  in  its  composition  re- 
mains to  be  demonstrated.  This  bone  plug  consists  of  sixty  parts — by  weight 
— of  iodoform,  forty  parts  spermaceti,  and  forty  parts  oleum  sesami.  These 
ingredients  are  slowly  heated  to  100.°  C.  and,  when  allowed  to  cool,  they  form  a  soft 
mass  which  remains  solid  at  the  temperature  of  the  body.  For  use  it  is  heated 
to  50°  C,  being  constantly  stirred  to  keep  the  iodoform  evenly  distributed. 
This  material  does  not  act  as  a  foreign  body,  nor  as  a  culture  medium. 
It  possesses  the  inhibitory  and  medicinal  properties  of  iodoform  without 
causing  iodoform  intoxication.  Its  physical  properties  are  such  that  it  is  grad- 
ually absorbed  and  replaced  by  granulations  and  finally  by  bone.  Bone  cav- 
ities are  emptied  of  sequestra  and  detritus  and  are  then  sterilized  by  ninety- 
five-per-cent  carbolic  acid  followed  by  alcohol;  they  are  then  thoroughly  dried 
and  filled  with  the  melted  preparation,  which  at  the  temperature  of  the  body 
speedily  solidifies.  The  periosteum  and  deeper  soft  parts  are  then  closed  with 
catgut,  and  the  integument  with  silk  or  silkworm  gut,  and  finally  a  surgical 
dressing  is  applied.  The  results  in  chronic  osteomyelitis  and  tuberculosis  are 
most  gratifying.  The  method  is  not  applicable  in  acute  cases  because  the  cavi- 
ties cannot  be  made  sterile. 

LIGATURES  AND  SUTURES;  SURGICAL  DRESSINGS. 

Sutures  of  various  materials  have  been  used  by  surgeons  for  the  closure  of 
wounds  from  a  very  early  period.  Ligatures  for  the  control  of  hemorrhage 
were  used  by  Celsus  in  the  first  century  of  the  Christian  era,  and  by  Galen  and 
others  later,  but  hemorrhage  was  usually  controlled  by  the  cautery  and  hot 
oil  until  1564,  when  Ambroise  Pare  earnestly  advocated  and  practised  the  use 
of  the  ligature.     It  was  not  generally  accepted,  however,  until  about  two  hundred 


GENERAL  SURGICAL  TREATMENT.  725 

years  later,  when  Mr.  Sharpe,  a  surgeon  of  Guy's  Hospital,  London,  was  largely 
instrumental  in  bringing  it  into  general  use. 

Ligature  and  suture  materials  are  of  two  varieties,  the  absorbable  and  non- 
absorbable. The  principal  varieties  of  the  non-absorbable  are  silk,  linen,  silk- 
worm gut,  horsehair,  wire  (silver,  gold,  iron),  and  Pagenstecher's  celluloid  hemp; 
the  absorbable  are  catgut  and  kangaroo  tendon.  Non-absorbable  ligature  and 
suture  material  of  some  variety  was  the  first  in  use,  and  was  the  best  for  clos- 
ing superficial  wounds  until  iodized  catgut  was  introduced. 

Silk  has  always  been  a  favorite  material  for  both  ligatures  and  sutures.  It 
is  easily  sterilized  by  steam  or  boiling,  is  smooth,  strong,  and  ties  securely.  It 
is  used  by  most  surgeons  at  the  present  time  for  intestinal  and  integumentary 
sutures,  and  there  are  still  many  who  use  fine  silk  for  ligatures  and  buried 
sutures.  Many  varieties  of  surgeons'  silk  are  on  the  market,  and  most  of  them 
are  good.  The  hard-twisted  varieties  are  the  best,  and  the  black  iron-dyed  silk 
has  the  advantage  of  being  easily  seen.  The  fine  and  medium  weights  are  all 
that  are  necessary.  The  finer  it  is  the  more  certainly  it  can  be  made  sterile 
and  the  less  likely  it  is  to  act  as  a  foreign  body.  In  the  days  of  septic  surgery 
heavy  braided  silk  was  frequently  used  for  ligating  arteries,  and  the  ends  were 
left  protruding  from  the  wound  so  that  it  could  be  removed  when  it  sloughed 
loose.  At  the  present  day  it  is  not  considered  necessary  to  use  heavj^  silk, 
and  it  is  imwise  to  bury  it,  for  obvious  reasons.  AVhen  heavy  silk  was  used  for 
ligating  arteries,  surgeons  believed  that  it  was  necessary  to  tie  the  ligature 
tightly  enough  to  cut  through  the  inner  coat  of  the  blood-vessel,  so  that  the  latter 
would  curl  up  and  facilitate  the  formation  of  a  clot.  Since  we  have  learned  that 
only  sufficient  force  is  required  to  hold  the  walls  of  the  vessel  close  together, 
fine  silk,  or  preferably  catgut,  is  used.  When  the  hea^^  silk  was  used  all 
wounds  were  septic  and  a  large  percentage  of  secondary  hemorrhages  occurred 
when  the  ligature  came  away.  In  those  days  the  surgeon  was  anxious  until 
the  tenth  or  fifteenth  day,  when  the  ligature  usually  came  away.  The  ligat- 
ing of  large  arteries  such  as  the  carotid  was  an  important  imdertaking  in  those 
days  because  secondary  hemorrhage  occurred  in  from  fifteen  to  thirty  per  cent  of 
cases  and  very  frequently  with  a  fatal  result.  The  aseptic  surgeon  ties  such  an 
artery  with  a  mediiun-sized  catgut  ligature  with  no  thought  of  secondary  hem- 
orrhage, which  is  practically  not  considered  in  modern  surgery.  In  the  old 
days  surgeons  were  afraid  to  tie  veins  because  of  the  disastrous  results  from 
sepsis,  but  bleeding  vessels  of  all  kinds  are  tied  now  with  safety  and  security. 
Without  the  aseptic  ligature  modern  surgery  would  be  impossible.  Thorough 
hffimostasis  is  a  very  essential  feature  of  our  technique.  In  the  septic  era  it 
was  considered  necessary  to  place  the  ligature,  if  possible,  not  less  than  one  inch 
from  any  important  branch  for  fear  of  hemorrhage,  but  now  that  is  given  second- 
ary consideration.  Senn  has  demonstrated  by  experiment  that  when  an  aseptic 
ligature  is  applied  it  is  either  removed  by  absorption  or  becomes  encysted  after 


726  AMEPJCAX  PRACTICE   OF  SURGERY. 

having  performed  the  function  of  a  proA'isional  haemostatic.  He  foimcl  that 
the  hunen  of  the  blood-vessel  becomes  obliterated  by  proliferation  of  new  tissue 
from  the  endothelial  and  coimective-tissue  cells  independently  of  thrombosis. 
The  constricted  portion  of  the  vessel  does  not  necrose,  but  becomes  infiltrated 
with  living  tissue.  After  the  application  of  a  septic  ligature  the  presence  of 
an  intravascular  thrombus  is  a  necessity,  but  after  an  aseptic  ligature  it  is  often 
entirely  absent.  '\^'hen  the  mtima  is  held  in  contact  long  enough  the  lumen  is 
obliterated  bj^  the  formation  of  a  minute  transverse  scar  strong  enough  to  resist 
the  blood  pressure.  As  early  as  twenty-four  hours  after  the  application  of  an 
aseptic  ligature  the  intima  becomes  adherent,  and  as  early  as  after  the  lapse  of  three 
days  Senn  fomid  a  narrow,  firm  cicatrix  mrderneath  the  ligature.  Nature  is  throw- 
ing plastic  material  around  the  outside  of  the  ligature  at  the  same  time,  so  that 
it  is  not  necessary  to  apph'  a  permanent  ligature  nor  one  that  will  last  more  than 
two  or  three  days.  In  tjing  a  silk  ligature  the  first  laiot  should  consist  of  but 
a  single  reef,  as  this  slips  do-rni  snugly  and  will  hold  until  a  second  knot  is  tied. 
Buried  ligatures  and  sutures  of  silk  can  be  used,  but  they  are  no  better  or  safer 
than  catgut  and  will  frequently  act  as  foreign  bodies  in  spite  of  every  precaution. 
One  who  is  thoroughly  familiar  with  the  use  of  catgut  would  never  think  of  using 
silk  as  a  buried  ligature,  and  will  use  it  as  a  buried  suture  in  intestinal  work  only. 
\^1ien  the  deeper  parts  of  a  woimd  are  closed  with  catgut  the  integument  may 
be  closed  with  silk,  but  iodized  catgut  is  better  for  this  purpose.  The  various 
arrangements  for  storing  and  carrying  sterilized  silk  so  much  employed  a  few  years 
ago  are  little  used  now.  It  is  better  to  sterilize  the  silk  before  each  operation 
by  steam  or  boiling.  Steam  is  better  because  repeated  boiling  weakens  the 
silk.  After  sterilization  it  should  be  kept  in  alcohol  or  sterile  water  during 
the  operation.  It  should  not  be  left  exposed  to  the  air.  For  carrying  in  an 
emergency  bag  it  can  be  sterilized  in  the  usual  mamier  and  then  kept  in  bottles 
filled  with  alcohol  or  carbolic  solution. 

Horsehair  is  a  favorite  material  for  integumentary  sutures  with  some  sur- 
geons. It  should  be  prepared  for  use  by  first  washing  it  thoroughly  with 
soap  and  water  and  then  it  should  be  steamed  or  boiled.  It  should  be  kept 
in  sterile  water  or  alcohol  during  the  operation. 

Silku'orm  gut  is  the  thread  drawii  from  a  silkworm  killed  when  ready  to 
spin  the  cocoon.  It  is  used  very  extensivelj^  in  surgery  for  stay  sutures  in  deep 
womids  and  for  closing  superficial  sutures,  and  is  a  very  valuable  material  for 
these  purposes.  It  is  pearly  white,  smooth,  easily  sterilized  by  steam  or  boil- 
ing, and  does  not  furnish  food  for  bacteria.  It  is  kept  in  bmidles  of  two  varieties, 
the  cheaper  variety  of  which  is  composed  of  strands  of  various  weights,  while  the 
more  expensive  variety  is  made  of  select  heaA7--weight  strands.  For  general 
work  the  cheaper  variety  is  very  convenient,  but  for  closing  the  abdominal 
wall  the  heavier  variety  only  should  be  used,  as  the  lighter  strands  are  liable 
to  break.     This  material  can  be  sterilized  bv  boiling  with  the  instrimients  and 


GENERAL   SURGICAL  TREATilEXT.  727 

kept  in  sterile  water  during  the  operation.  The  boiling  softens  it  sufficiently 
to  make  it  tie  well,  and  when  once  tied  it  does  not  slip.  Some  surgeons  make 
but  one  double  reef  knot  when  using  it,  but  an  additional  knot  requires  very 
little  time  and  is  safer.  Silkworm  gut,  as  a  material  for  buried  sutures  has  been 
found  unsuitable.  It  does  not  undergo  absorption  and  sooner  or  later  acts  as  a 
foreign  body.  It  is  most  commonly  used  for  deep  through-and-through  or  stay 
sutures  in  abdominal  woimds,  but  the  integument  should  be  approximated  by 
silk  or  iodized  catgut,  because  the  silkworm  gut  is  too  stiff  to  make  a  smooth 
running  stitch.  In  some  hospitals  the  silkworm  gut  is  stained  red  or  blue,  to 
denote  its  presence  under  all  circumstances.  If  properly  divided  it  is  easily 
removed  after  the  healing  of  the  wound.  Stitch  abscesses  are  comparatively 
infrequent  from  its  use. 

Pagenstecher' s  celluloid  yarn  is  being  extensively  used  as  a  substitute 
for  silk  in  intestinal  work  and  for  closing  superficial  wounds.  It  is  prepared  by 
boiling  linen  thread  for  thirty  minutes  in  a  one-per-cent  solution  of  sodium 
carbonate,  washing  in  boiling  water,  drying  between  sterile  towels,  and  finally 
soaking  in  a  celluloid  solution.  This  yarn  is  sterilized  by  steaming  or  boil- 
ing, is  very  firm  and  smooth,  and  does  not  absorb  secretions  readily.  It  is 
stronger  than  silk,  and  therefore  a  finer  thread  can  be  used.  It  is  rigid  enough 
to  be  readily  threaded  into  the  eye  of  the  needle  when  wet,  which  is  another 
great  advantage  over  silk.  It  ties  nicely,  and  when  once  tied  is  perfectly 
secure.  It  can  be  bought  from  instrument  dealers  in  various  sizes  and  is 
cheaper  than  silk.  Linen  thread  was  an  old-time  favorite  with  surgeons,  but 
has  been  practically  abandoned  because  of  its  unevenness  and  roughness,  but 
the  celluloid  process  overcomes  these  and  other  objections,  so  that  it  is  doubt- 
less destined  to  become  an  acceptable  agent. 

Silver  ivire  still  occupies  a  place  in  surgical  technicjue,  but  not  nearly  so 
prominent  a  one  as  formerly,  because  in  many  places  where  it  was  once  used  the 
absorbable  suture  is  now  employed.  In  the  early  days  of  gynecology  it  was  much 
used  as  a  suture  material  by  Marion  Sims  and  others.  Sims'  early  victories 
in  closing  vesico-vaginal  fistula  were  doubtless  largely  due  to  the  fact  that  he 
used  wire  sutures  which  were  more  likely  to  be  sterile  than  other  materials 
without  thorough  preparation.  With  asepsis,  however,  either  absorbable  sut- 
ures or  silk  may  be  used.  There  is  at  present  but  little  excuse  for  using  wire  as 
a  buried  suture  in  the  soft  tissues,  because  the  absorbable  suture  meets  aU  the 
reciuirements  and  is  free  from  the  objections  to  wire.  Wire  can  be  made  sterile 
by  boiling,  but,  when  left  in  the  soft  tissues,  it  too  often  makes  trouble  later  by 
causing  abscesses  and  fistulte.  It  was  applied  quite  extensively  at  one  time  in 
the  operation  for  the  radical  cure  of  hernia.  The  silver  filigree,  a  coarse  mesh 
of  silver  wire,  has  been  recommended  as  a  filling  in  extensive  ventral  hernias,  but 
its  superiority  over  other  methods  has  not  been  demonstrated.  The  application  of 
silver  wire  in  surgery  is  practically  restricted  to  the  treatment  of  fractures  at  the 


728  AMERICAN  PRACTICE   OF   SURGERY. 

present  time,  and  even  there  the  chromicized  catgut  is  often  preferable.  In 
the  treatment  of  fractured  patella,  for  example,  it  has  been  demonstrated  that 
the  fragments  can  be  held  together  bj'  suturing  the  periosteum  and  surrounding 
fascia  with  chromicized  catgut,  thus  avoiding  the  necessity  for  drilling  the  frag- 
ments, and  the  dangers  of  a  foreign  body  in  the  tissues.  There  are  many  cases 
of  fracture,  however,  in  which  silver  wire  is  doubtless  the  best  material  at  our 
command  for  holding  the  fragments  together.  It  is  strong,  pliable,  and  can  be 
made  absolutely  sterile  by  boiling.  If  the  wound  is  aseptic  it  can,  as  a 
rule,  be  buried  m  these  cases  with  no  unpleasant  after-effects.  Occasionally, 
however,  it  will  act  as  a  foreign  body  some  time  later.  In  septic  cases  of  com- 
poimd  fracture  it  is  sometimes  used  with  the  expectation  that  it  shall  be  re- 
moved later,  but  its  use  is  not  free  from  danger  in  these  cases  and  its  advantages 
are  questionable.  In  wiring  fractures  the  wire  is  passed  through  holes  drilled 
in  the  fragments  for  the  purpose,  the  fragments  are  adjusted,  and  the  two  ends 
of  the  wire  twisted  until  the  fragments  are  held  snugly  m  place.  It  must  not 
be  twisted  too  tight  or  it  will  break,  but  it  must  be  tight  enough  to  prevent  too 
free  movement  of  the  fragments.  The  end  of  the  twisted  wire  is  cut  off 
half  an  inch  or  so  from  the  bone  and  bent  do^Ti  flat  against  the  bone  so  that 
it  cannot  interfere  with  the  neighboring  muscles.  Silver  wire  has  been  recom- 
mended as  a  longitudinal  suture  for  closing  an  abdominal  wound,  but  it  pos- 
sesses a  doubtful  advantage  over  the  absorbable  suture  usually  employed, 
is  more  expensi^'e  and  more  difhcult  to  apply  properly.  Wire  should  be  pre- 
pared before  each  operation  by  boiling  with  the  instrimients,  and  should  be 
kept  in  sterile  water  until  used.     The  medium  weight  is  best  for  ordinary  use. 

Absorbable  sutures  are,  next  to  asepsis  itself,  the  most  prominent  feature  of 
aseptic  surgery.  Catgut  and  kangaroo  tendon  are  about  the  only  animal  sutures 
now  used,  and  the  former  is  cheaper  and  more  easily  prepared,  and  meets  every 
indication  for  ligature  and  buried  suture  so  admirably  that  rarely  is  any  other 
needed.  Animal  ligature  was  first  suggested  by  Dr.  Physic,  of  Philadelphia, 
in  1814.  Dr.  Jameson,  of  Baltimore,  used  deerskin  cut  into  narrow  strips  and 
firmly  rolled,  and  he  tied  all  of  the  accessible  arteries  with  it.  Sir  Astley 
Cooper  tied  the  femoral  artery  with  catgut.  Nussbaum  said,  "  Catgut  is  with- 
out doubt  Lister's  greatest  discovery." 

Catgut  as  prepared  now  is  a  universal  favorite  among  those  who  have  learned 
to  use  it.  It  did  not  gain  its  present  high  place  in  the  estunation  of  surgeons 
without  great  opposition.  Lister's  methods  of  sterilization,  as  well  as  those  of 
manj'  others,  were  at  times  disappointing,  and  the  plan  of  bmying  the  catgut 
in  the  wound  and  leaving  it  there  naturally  became  the  target  for  severe  criti- 
cism. It  was  the  scapegoat  for  every  slip  in  technique.  It  was  customary  for 
the  sm-geon  who  used  a  faulty  teclinique  and  was  constantly  getting  infected 
wounds,  to  blame  the  catgut  instead  of  blaming  himself,  but  the  results  ob- 
tained with  it  now  silence  criticism.     There  are  a  few  good  surgeons  who  do 


GENERAL  SURGICAL  TREATMENT.  72^ 

not  use  it.  The  statements  that  it  was  not  always  sterile  in  former  days,  and 
that  it  may  not  be  sterile  now,  are  just  as  true  of  catgut  as  they  are  of  silk 
or  any  other  material,  but  it  is  equally  true  that  it  can  be  and  is  made  sterile. 
The  old  objection  that  it  does  not  last  long  in  the  tissues  is  now  acknowledged 
to  be  a  great  virtue.  The  objection  that  it  cannot  be  tied  properly  is  disproved 
by  every  one  who  uses  it  with  care.  Secondary  hemorrhage  occurred  when 
silk  and  other  like  materials  were  used,  not  because  of  the  materials,  but  on 
account  of  sepsis.  Surgeons  who  habitually  use  catgut  rarely  have  secondary 
hemorrhages.  Catgut  swells  after  being  in  the  tissues  for  a  time,  but  the  swell- 
ing has  a  tendency  to  tighten  rather  than  loosen  the  ligature.  In  tying  catgut 
it  is  necessary  to  make  a  double  reef  for  the  first  knot,  because  one  reef  will 
not  hold  securely  until  the  next  one  is  made.  The  material  is  so  slippery  that 
the  double  reef  may  easily  be  tied,  and  it  will  hold  securely  whUe  one  or  twa 
additional  reefs  are  tied.  The  facts  that  catgut  can  be  broken  when  tied  too- 
tightly,  and  that  it  will  slip  when  improperly  tied,  are  commendable  virtues, 
because  they  discourage  tight  ligatures  and  careless  tymg.  It  is  not  an  un- 
common error  among  surgeons,  especially  begijoners  in  the  use  of  catgut,  to  use 
too  large  a  size.  One  accustomed  to  the  use  of  catgut  feels  perfectly  secure  in 
using  the  medium  and  finer  grades  because  his  experience  teaches  him  that  they 
meet  every  indication.  The  heavier  grades,  aside  from  containing  too  much  ma- 
terial, are  more  difficult  to  tie  and  to  sterilize.  When  there  is  a  doubt  in  the 
surgeon's  mind  as  to  the  catgut  having  sufficient  textile  strength  in  a  given  case  it 
is  wise  to  use  a  double  strand  of  a  finer  gut  than  to  use  a  coarse  strand,  because  the 
double  strand  affords  the  desired  strength,  exposes  a  larger  sm-face,  and  is  more 
readily  absorbed.  Experience  has  taught  us  that  all  kinds  of  ligature  material  will 
become  encysted  if  aseptic,  but  that  an  inabsorbable  material  when  tied  aroimd 
an  artery  may  weaken  the  vessel  at  that  place,  while  an  absorbable  ligature  acts 
equally  well  as  a  temporary  hasmostatic  and  is  gradually  replaced  by  living 
tissue,  thus  strengthening  the  vessel.  Catgut  can  be  hardened — so  that  it  will 
last  ten,  twenty,  thirty,  or  forty  days  in  the  tissues — by  adding  different  per- 
centages of  chromic  acid  to  it,  making  the  chromicized  catgut  of  commerce. 
The  principal  advantage  of  the  chromicized  gut  is  that  it  enables  the  surgeon  to 
use  a  finer  strand.  The  heavy  chromicized  gut  and  that  containing  an  excessive 
amovmt  of  the  hardening  agent  are  objectionable  because  the  knots  imdergo 
absorption  very  slowly  and  are  liable  to  act  as  a  foreign  body.  For  this  reason 
the  chromicized  gut  should  not  be  used  when  the  plain  gut  will  answer  the 
pmpose  just  as  well.  Infection  occurs  more  frequently  with  the  chromicized 
than  with  plain  catgut.  The  use  of  the  chromicized  gut  is  largely  a  habit ;  it 
is  rarely  necessary,  because  the  plain  gut  meets  most  requirements.  Plain  cat- 
gut is  not  a  good  material  for  superficial  sutures  which  are  required  to  carry 
any  weight,  because  the  lighter-weight  gut  becomes  absorbed  too  quickly  and 
the  heavier  readily  becomes  infected  from  outside  or  from  the  bacillus  which 


730  AMERICAN  PRACTICE  OF  SURGERY. 

has  its  habitat  in  the  skin.  The  iodized  catgut  of  medium  weight  is,  how- 
ever, admirably  adapted  for  this  purpose  because  it  lasts  long  enough,  does 
not  become  infected,  and  does  not  have  to  be  removed. 

Buried  sutures  are  a  most  essential  feature  of  aseptic  surgery,  and  the  best 
material  for  the  purpose  has  long  been  a  moot  point  among  surgeons.  The 
essential  requirements  of  an  ideal  material  for  buried  sutures  are,  first,  absolute 
sterility;  second,  adequate  and  uniform  tensile  strength;  third,  flexibility,  so 
that  it  will  tie  easily  and  securely;  and,  fourth,  a  proper  degree  of  absorba- 
bility. Catgut  as  now  prepared  meets  ^vith  all  these  requirements  perfectly, 
and  no  other  material  does.  Some  surgeons  maintain  that  an  ideal  cat- 
gut must  be  mildly  antiseptic.  They  claim  that  the  presence  of  the  antiseptic 
prevents  the  softened  catgut  from  acting  as  a  culture  medium;  but  the  soft 
tissues  are  very  intolerant  of  chemicals  of  all  kinds  and  it  is  an  open  question 
whether  the  antiseptic  does  not  do  more  harm  than  good,  for  we  have  long  since 
learned  that  wounds  heal  better  when  no  chemicals  have  been  applied  to  them. 
Silk  and  other  inabsorbable  materials,  including  catgut  with  an  overabund- 
ance of  hardening  material  which  makes  it  practically  inabsorbable,  have  been 
extensively  used  for  buried  sutures,  but  they  are  objectionable  and  unnecessary. 
They  are  objectionable  because  the}'  more  often  than  catgut  act  as  foreign  bodies, 
causing  abscesses  and  sinuses.  They  are  unnecessary  because  they  are  useful  only 
■during  the  healing  of  the  wound,  which  is  accomplished  in  a  few  days,  and  com- 
mon catgut  meets  this  indication  and  then  disappears,  while  the  inabsorbable 
material  remains  and  is  likely  to  cause  harm.  If,  after  the  healing  of  the 
wound,  the  newly  formed  tissues  begin  to  give  way,  the  sutures  are  power- 
less to  hold  them  because  pressure  necrosis  takes  place  and  the}'  cut  through. 
It  is  well  known  that  when  for  any  reason  a  superficial  womid  fails  to  imite, 
the  stitches  not  only  fail  to  prevent  the  wound  from  gaping,  but  soon  become  a 
source  of  irritation  and  stitch  abscesses  and  must  be  removed.  When  a  post- 
operative hernia  occurs  after  the  use  of  an  absorbable  suture  there  is  no  sup- 
puration or  sinus  further  to  weaken  the  parts;  but  when  unabsorbable  sutures 
have  been  used  they  cause  pressure  necrosis  and  may  and  often  do  cause  ab- 
scesses and  sinuses  which  not  only  aggravate  the  hernia  but  cause  the  patient 
pain  and  expose  to  danger. 

Kangaroo  tendon  has  been  introduced  and  ably  advocated  by  Dr.  Marcy 
•as  a  substitute  for  catgut  as  a  suitable  material  for  buried  sutures.  It  is  a  good 
material,  but  catgut  is  better,  cheaper,  and  easier  to  prepare.  The  larger  size 
■of  the  kangaroo  strand,  once  claimed  as  an  advantage,  is  now  believed  by 
■many  to  be  a  disadvantage. 

That  there  are  so  many  methods  of  preparing  catgut  is  evidence  that  its 
preparation  is  important  and  by  no  means  simple.  It  requires  much  more 
care  and  trouble  for  its  sterilization  than  the  various  inabsorbable  suture  ma- 
terials, but  its  superiority  over  all  those  materials  makes  it  well  worth  while. 


GENERAL  SURGICAL  TREATMENT.  731 

That  catgut  can  be  perfectly  sterilized  by  several  methotls  is  now  an  es- 
tablished fact,  but  no  one  method  is  yet  generally  accepted  as  the  best.  Un- 
fortunately, laboratory  tests  after  chemical  preparation  of  catgut  are  not 
reliable  because  methods  of  removing  the  chemical  from  the  catgut  before  the 
bacteriologic  test  are  not  eminently  practical.  Catgut  cannot  be  sterilized  by 
boiling  in  water  or  by  steaming  because  it  is  thus  destroyed,  but  it  can  be 
boiled  in  other  media  and  be  sterilized  by  dry  heat.  Chemical  methods  were 
at  first  quite  disappointing,  but  some  of  them  have  become  so  perfected  that 
they  are  now  quite  reliable.  The  so-called  catgut  is  prepared  from  the 
fibrous  coat  of  the  small  intestine  of  the  sheep.  The  best  catgut  on  the 
market  comes  from  the  German  manufacturers  and  the  exact  method 
of  its  preparation  is  somewhat  of  a  trade  secret,  but  it  is  evidently 
prepared  with  greater  care  than  formerly  because  it  is  frequently  sterile 
without  special  preparation.  Different  manufacturers  prepare  different  sizes 
of  catgut,  designating  the  different  sizes  by  number.  Unfortimately,  each  rnan- 
ufacturer  has  a  scale  of  his  o\m.  which  may  lead  to  mistakes  when  ordering 
the  material.  Three  sizes — fine,  mediimi,  and  coarse — are  sufficient  for  all 
purposes.  The  medium  size  is  the  one  most  commonly  used.  The  finest  strand 
is  used  only  where  it  is  necessary  for  it  to  hold  for  one  or  two  days,  or  when  it  is 
employed  upon  small  arteries  and  the  peritoneum.  The  medium  size  will  last 
five  or  six  days  in  the  tissues,  which  makes  it  suitable  for  ligating  arteries,  ex- 
cepting the  very  largest,  and  for  buried  sutures  generally.  The  heavier  strands 
are  seldom  used,  surgeons  generally  preferring  to  use  chromicized  gut  when  a 
more  durable  ligature  or  suture  material  is  required.  The  medium-weight 
catgut  has  all  the  tensile  strength  ever  required.  The  day  of  tight  ligatures 
is  past,  and  one  who  breaks  the  medium  weight  catgut  is  using  more  strength 
than  is  necessary. 

Claudius'  method  or  the  iodine  method  is  one  of  the  most  recent  and  popular 
chemical  methods  of  catgut  sterilization.  Senn  has  used  this  method  exclusively 
for  over  two  years  with  entire  satisfaction  in  his  clinics  and  in  private 
practice.  During  this  time  he  has  had  hundreds  of  cultures  made  without  pos- 
itive results  in  a  single  instance.    The  method  is  thus  described : 

"  The  commercial  raw  catgut,  without  any  preliminary  preparation,  is  -wound 
on  a  glass  roll,  two  strings  tied  together  to  each  roll.  The  sterilization  is  effected 
by  immersion  in  a  one-per-cent  solution  of  iodine.  The  solution  is  made  by 
dissolving  one  part  of  iodine  and  one  part  of  potassium  iodide  in  one  hundred 
parts  of  water.  The  potassium  iodide  is  dissolved  in  a  small  cjuantity  of  water 
to  which  the  iodine,  finely  pulverized,  is  added  and  the  concentrated  solution 
is  then  diluted  to  one  per  cent.  The  solution  and  catgut  are  kept  in  a  bottle 
with  a  wide  mouth  which  is  closed  with  an  accurately  fitting  glass  stopper. 
The  date  is  written  on  the  label  of  the  bottle.  After  eight  days  the  catgut  is 
ready  for  use,  and  is  preserved  in  the  same  bottle  and  in  the  same  solution. 


732  AMERICAN  PRACTICE  OF  SURGERY. 

Before  being  used,  the  catgut  is  immersed  on  a  glass  roll  in  a  three-per-cent  solu- 
tion of  carbolic  acid,  or  an  indifferent  sterile  fluid,  for  the  purpose  of  removing 
the  iodine  from  the  surface  of  the  threads.  The  threads  are  cut  in  the  solution 
as  they  are  needed.  The  catgut  not  used  in  the  operation  is  returned  into  the 
bottle,  thus  domg  away  with  unnecessary  waste  of  material.  The  catgut  thus 
prepared  is  pitch  black,  soft,  pliable,  and  almost  as  strong  as  silk.  The  knots 
are  firm  and  not  liable  to  slip  or  become  untied.  Catgut  prepared  by  this 
method,  according  to  its  size,  resists  absorption  for  from  twelve  to  sixteen  days. 
Iodized  catgut  is  not  only  absolutely  sterile,  but  at  the  same  time  is  antiseptic. 
The  catgut  remains  in  the  aqueous  iodine  solution,  without  loss  of  tensile  strength, 
for  several  weeks.  If  it  is  desirable  to  preserve  it  for  a  longer  time  it  is  advis- 
able to  transfer  it  after  eight  days  to  an  alcoholic  solution  of  similar  strength." 
It  cannot  be  kept  long  in  sterile  water  because  the  water  removes  the  iodine 
and  softens  and  destroys  the  gut.  This  is  certainly  the  simplest  of  all  methods 
of  catgut  sterilization  and  the  one  that  naturally  appeals  to  those  who  prepare 
their  own  material.  Some  who  gave  the  iodine  catgut  a  trial  have  abandoned 
it  because  it  soon  became  brittle,  and  others  because  the  iodine  was  too  irritating. 
Senn  claims  that  the  brittleness  is  due  to  the  material  used  and  not  to  the 
method. 

Abbott,  of  Mimieapolis,  has  found  that,  by  using  but  half  the  quantity  of 
iodine  recommended  by  Claudius,  the  catgut  is  quickly  and  surely  sterilized 
and  does  not  become  brittle  or  irritating.  He  uses  but  two  sizes,  the  fine  and 
the  medium.  He  fuids  that  the  fine  thread  prepared  in  this  manner  lasts  one 
week  and  makes  a  very  satisfactory  cutaneous  stitch.  He  prepares  the  chro- 
micized  gut  by  immersing  the  raw  catgut  for  twenty-four  hours  in  a  1  :  2000 
aqueous  solution  of  chromic  acid,  after  which  it  is  sterilized  in  the  iodine  solution 
in  the  usual  manner.  After  eight  days  he  transfers  the  iodized  gut  to  ninety- 
five-per-cent  alcohol  and  uses  it  from  that  medium.  To  avoid  the  tendency  to 
become  brittle  he  suggests  that  it  is  better  to  prepare  the  gut  frequently  in 
smaller  quantities  than  to  prepare  a  large  quantity  which  must  be  kept  in  solu- 
tions for  a  long  time.  He  has  used  catgut  prepared  in  this  manner  for  two 
years  and  is  perfectly  satisfied  with  it.  He  believes  that  this  method  is  supe- 
rior to  all  others  because  it  is  so  simple  and  so  efficient. 

We  are  greatly  indebted  to  Moschcowitz,  of  New  York,  for  much  valuable 
information  concerning  iodine  catgut.  He  and  Gerster  have  used  it  in  Moimt 
Sinai  Hospital  for  nearly  three  years  and  in  no  case  have  they  had  the  slightest 
occasion  to  regret  their  confidence  in  it.  Moschcowitz,  like  many  others,  fotmd 
that  after  a  time  catgut  prepared  and  preserved  by  the  original  Claudius  method 
had  a  tendency  to  become  brittle,  and,  like  Abbott,  he  has  been  experimenting 
to  find  and  remove  the  cause.  He  has  learned  that  when  the  gut  is  removed 
from  the  iodine  solution  at  the  end  of  eight  days  and  kept  in  a  dry  sterile  jar 
it  does  not  become  brittle,  and  he  has  been  using  this  dry  gut  for  the  past  nine 


GENERAL   SURGICAL  TREATMENT.  733 

months  with  perfect  satisfaction.  "  It  is  used  dry,  just  as  it  is  cut  from  the  spool, 
without  any  previous  immersion  in  carbohc  sohition  or  sterile  water.  Any 
imused  catgut  may  be  resterilized  on  a  future  occasion."  He  says  that  this 
dry  gut  is  somewhat  stiff  like  a  fine  wire,  but  that  it  has  no  tendency  to  kink 
up,  and  when  used  it  soon  becomes  soft.  He  knows  of  no  disadvantages  con- 
nected with  this  gut.  He  has  made  a  large  number  of  experiments,  from 
which  and  from  his  practical  experience  he  draws  the  following  conclusions : 

1.  The  "dry"  iodine  catgut  is  absolutely  sterile. 

2.  It  is  impossible  to  infect  it  by  ordinary  means. 

3.  Its  imbibition  with  iodme  is  not  sufficient  to  make  it  act  as  an  irritant 

upon  the  tissues. 

4.  Its  tensile  strength  is  superior  to  that  of  raw  catgut  and  to  that  pre- 

pared by  the  sublimate-alcohol  method. 

5.  It  is  easily  and  cheaply  prepared. 

6.  It  is  absorbed  only  after  it  has  served  the  purpose  for  which  it  was  in- 

tended. 

The  Bartlett  Method.— This  method,  devised  by  Dr.  Willard  Bartlett,  seems 
destined  to  supersede  all  other  methods  of  preparing  catgut.  The  sterilization 
is  effected  by  the  use  of  both  heat  and  iodine.  The  boiling  in  petrolatum  destro3rs 
every  vestige  of  germ  life  and  at  the  same  time  renders  the  gut  soft  and  pliable. 
The  subsequent  preservation  in  an  iodine  solution  renders  it  antiseptic  and 
protects  it  from  infection ;  at  the  same  time  the  iodine  does  not  seem  to  irritate 
the  tissues  as  other  chemicals  do.  The  following  is  Dr.  Bartlett's  description 
of  his  method: 

"The  process  can  be  divided  into  three  steps:  (1)  The  physical  prepara- 
tion of  the  material ;   (2)  its  sterilization;   (3)  its  storage. 

'  L  The  ordinary  commercial  ten-foot  catgut  strand  is  divided  into  four 
equal  lengths,  each  of  which  is  made  into  a  little  coil  about  one  inch  and  a  half 
in  diameter.  By  twisting  the  last  free  end  about  four  times  around  this  little 
coil  the  latter  will  maintain  its  shape.  These  coils  in  any  desired  number  (I 
usually  take  about  one  hundred  and  twenty  of  them  at  a  time)  are  strung  on 
a  thread,  like  beads  on  a  string,  in  order  that  the  whole  number  may  be  handled 
at  once.  This  string  of  coils  is  hung  in  a  metal  can,  better  still  in  a  beaker  glass, 
but  is  not  allowed  to  touch  the  bottom  or  sides.  I  suspend  them  by  carrying 
the  two  ends  of  thread  through  a  small  opening  in  a  pasteboard  cover  which 
is  placed  on  the  receptacle.  The  same  opening  serves  to  admit  a  thermometer, 
which  is  carried  clown  to  exactly  the  point  where  its  mercury  bulb  is  on  a  level 
with  the  topmost  coils.  Liquid  petrolatimi  is  now  poured  in,  the  quantity 
being  sufficient  to  immerse  the  catgut  and  the  bulb  of  the  thermometer. 

"  2.  Thevessel  is  setupona  pan  of  sand  under  which  is  placed  a  tiny  gas  flame 
of  merely  sufficient  intensity  to  raise  the  temperature  of  the  oil  to  212°  F.  within 
from  one  to  two  hours.     A  little  practice  enables  one  to  guess  the  size  of  flame 


734  AMERICAX  PRACTICE  OF  SURGERY. 

necessarj'  for  this  purpose.  This  is  best  done  in  the  evening,  and  the  temper- 
ature should  be  allowed  to  remain  at  about  212°  F.  (a  variation  of  a  few  degrees 
does  not  matter)  until  morning.  The  heat  is  then  increased  to  such  an  extent 
that  the  temperatm-e  will  run  up  to  300°  F.  in  the  coiu-se  of  an  hour:  then 
the  gas  is  turned  off  and  the  temperatm-e  of  the  oil  allowed  to  return  to  about 
212°. 

"  3.  The  pasteboard  cover,  together  with  the  string  of  catgut  coils,  is  lifted 
off,  the  superfluous  oil  is  allowed  to  drop  off,  and  then  the  tliread  is  cut,  per- 
mitting the  coils  to  drop  into  the  following  mixtm-e : 

Columbian  spirits 100  parts 

Iodine  flalces 1  part 

"  The  catgut  is  now  ready  for  immediate  use,  and  will  keep  without  dete- 
riorating for  anjdength  of  time.  The  jar  maj- be  opened  anj'  number  of  times 
so  long  as  a  sterile  instrmnent  is  used  for  removing  the  coils,  since  the  iodine 
protects  the  coils  that  are  left  behind  from  accidental  contamination." 

In  a  personal  communication  from  Dr.  Bartlett  in  reply  to  an  inquiry 
concerning  his  method  of  chromicizing  catgut,  he  makes  the  following  state- 
ment : 

"  I  have  given  up  the  use  of  chromic  or  other  acids  in  the  treatment  of  cat- 
gut, and  use  formalin  A-apor  where  I  desire  to  make  catgut  last  longer  than 
usual.  I  simply  suspend  the  coils  a  few  inches  above  a  ten-per-cent  formalin 
solution  in  an  airtight  A-essel  for  twenty-four  hom-s.  This  is  far  simpler  than 
immersing  it  in  the  solution,  and  the  catgut  recpires  no  washing  afterward. 
No.  2  catgut  so  treated  will  last  for  between  two  and  tliree  weeks  in  muscle 
tissue." 

Ochsner's  Method. — The  following  method  of  preparing  catgut  has  been  em- 
ployed at  the  Augustma  Hospital  for  years  with  perfect  satisfaction.  "  Catgut 
is  prepared  bj^  immersion  in  sulphuric  ether  for  one  month,  then  for  one  month 
in  strong  conunercial  alcohol  in  which  one  grain  to  the  ounce  of  corrosive  sub- 
limate has  been  dissolved,  the  solution  being  renewed  once  during  this  time. 
It  is  then  preserved  indefuriteh'  in  a  solution  of  one  part  iodoform,  five  parts 
of  ether,  and  fourteen  parts  of  strong  commercial  alcohol.  It  should  never  be 
handled  bj'  any  one  except  the  surgeon  and  the  chief  assistant.  Tliis  catgut 
will  last  seven  to  ten  days  m  tissues,  according  to  the  size  used.  It  is  emploj^ed 
in  all  ligatiu-es,  both  in  the  peritoneal  ca^'it}-  and  elsewhere,  and  for  all  buried 
sutures  except  in  hernias  and  in  the  suturing  of  bones.  For  these  purposes  a 
chromicized  catgut  is  employed,  which  lasts  for  from  fifteen  to  thirty  days  accord- 
ing to  size.  This  is  prepared  after  the  following  formula:  The  catgut  is  im- 
mersed in  ether  for  one  month,  then  in  a  solution  prepared  in  the  foUo'u-ing  man- 
ner: 

'B,  (A)  Chromic    acid 1  part    (B)    Take  of  solution  A 1  part 

Water 5  parts  Glj'cerin 5  parts 

(Carefully  dissolve.) 


GENERAL  SURGICAL   TREATMENT.  735 

Take  solution  B  and  soak  therein  catgut  for  forty-eight  to  ninety-six  hours, 
according  to  the  resistance  wanted.  That  soaked  for  forty-eight  hours  will  re- 
sist absorption  by  the  tissues  for  fifteen  days;  that  for  ninety-six  hours  will 
resist  for  thirty  days.  (C)  Take  catgut  out  of  solution  B,  rinse  quickly  in  ster- 
ilized water  to  free  it  from  solution  B,  stretch  and  rub  ciuickly  with  a  hard, 
sterile  towel  to  remove  any  of  solution  B  which  may  still  be  adhering  to  it,  wind 
on  rods  or  slides  at  least  three  inches  in  length,  and  preserve  indefinitely  in  the 
following  solution: 

(D)  Carbolic  acid  95  per  cent 1  part 

Glycerin .5  parts 

The  catgut  may  remain  in  this  solution  for  many  months  without  depreciating 
in  quality,  or  it  may  be  kept  for  an  indefinite  period  of  time  in  the  same  solution 
as  the  ordinary  catgut,  composed  of: 

Iodoform 1  part 

Ether 5  parts 

Strong  alcohol 14  parts 

The  jar  containing  the  ether  in  which  the  catgut  is  kept  for  one  month  should 
be  filled  only  about  one  half  with  the  loose  coils  of  ligature  and  then  it  should 
be  filled  with  ether ;  it  should  be  closed  airtight  and  should  be  picked  up  every 
day  or  two  and  shaken  in  an  inverted  position  in  order  to  wash  off  any  sub- 
stance which  may  accumulate  upon  the  surface  of  the  coils.  At  the  end  of 
two  weeks  the  ether  should  be  removed  and  fresh  ether  substituted.  The  same 
precaution  should  be  taken  with  the  solution  of  corrosive  sublimate  in  alcohol. 
It  is  especially  important  not  to  wind  the  catgut  tightly  before  placing  it  in 
these  solutions,  because  this  may  prevent  the  solutions  from  penetrating  all 
parts  of  the  material.  One  precaution  is  necessary  in  the  use  of  catgut  pre- 
pared in  this  manner — it  must  not  be  placed  in  water  before  it  is  used  at  the 
time  of  the  operation." 

Koenig's  method  of  boiling  catgut  in  cumol  is  a  good  and  reliable  one,  but  is 
only  suitable  for  large  hospitals  where  they  have  a  special  apparatus  for  this 
purpose.  This  method  as  modified  by  Clark  and  Miller  is  used  m  St.  Luke's 
Hospital,  of  New  York,  and  in  Johns  Hopkins  Hospital,  of  Baltimore,  with  per- 
fect satisfaction. 

The  New  York  Hospital  Method.—"  The  raw  gut  is  put  in  benzin  for  twenty- 
four  hours  to  remove  fat;  it  is  then  wiped  dry,  wound  on  glass  spools,  and  boiled 
in  alcohol  for  an  hour  to  an  hour  and  a  half,  the  time  varying  according  to 
the  size  of  the  gut.  After  twenty-four  hours  the  gut  (stiU  remaining  in  the 
alcohol)  is  boiled  for  half  an  hour  to  kill  any  spores  which  may  remain,  and  is 
then  ready  for  use.  It  is  kept  in  sterile  alcohol  vmtil  used."  This  gut  is  ster- 
ile, but  breaks  more  easily  than  that  prepared  by  the  cumol  method. 

The  Boechnann  method  of  sterilization  by  dry  heat  is  a  most  excellent  one 
but  requires  special  apparatus  and  extra  care  in  its  management,  so  that  it  is  not 


736  AMERICAN  PRACTICE  OF  SURGERY. 

a  choice  method  except  for  manufacturers.  In  the  Northwestern  Hospital,  of 
MinneapoUs,  and  in  many  other  hospitals  in  the  Middle  West,  the  Boeckmann 
catgut,  prepared  in  the  Ramsey  County  Medical  Society's  laboratory,  has  been 
used  for  years  with  great  satisfaction.  This  gut  can  be  bought  plain  or  im- 
pregnated with  pyoktanin.  It  is  sterile,  and  when  dipped  in  sterile  water 
just  a  moment  before  using  ties  very  easily  and  securely.  The  best  feature  of 
this  gut,  aside  from  its  reliability,  is  that  it  is  put  up  in  small  paper  envelopes 
which  can  be  carried  more  conveniently  than  bottles  or  glass  tubes.  It  is 
wrapped  in  two  layers  of  parafRn  pajaer  and  then  hermetically  sealed  in  a  small 
paper  envelope  and  properly  labelled.  This  is  all  done  before  the  sterilization, 
thus  avoiding  all  handling  of  the  gut  afterward.  These  envelopes  are  placed  in 
a  hot-air  sterilizer  and  kept  at  280°  F.  for  tlu-ee  hours  or  more,  which  makes  the 
gut  perfectly  sterile.  The  envelope  can  be  taken  in  mrsterile  hands,  the  end 
torn  off  and  the  enclosed  coil  of  gut  with  its  paraffin  wrappers  dropped  into  a 
sterile  hand. 

The  writer  has  used  catgut  prepared  by  the  Boeckmann  method  for  a 
number  of  years  with  great  satisfaction,  but  he  is  now  introducing  the  Bartlett 
catgut  into  the  Northwestern  Hospital  because  it  is  much  cheaper  and  more  suit- 
able for  superficial  stitches. 

Cargile  membrane  is  a  sterile  animal  membrane  first  prepared  for  the  pre- 
vention of  peritoneal  adhesions  and  later  adapted  to  a  variety  of  purposes  in 
wound  treatment.  It  is  prepared  plain  and  chromicized  and  compares  in  ab- 
sorbabilit}''  with  plain  and  chromicized  catgut.  Experimental  and  practical 
use  demonstrate  that  it  is  of  limited  advantage  in  pre^'enting  adhesions 
in  some  instances,  but  that  its  use  in  the  peritoneal  cavity  is  not  all  that  had 
been  hoped  for,  because  it  acts  as  a  foreign  JDody  and  becomes  covered  over  by 
omental  adhesions.  Morris,  Deaver,  and  others  have  used  it  in  the  human  abdo- 
men, but  as  yet  there  has  not  been  sufficient  opportmiity  to  examine  the  results 
and  thus  to  establish  its  real  value.  Craig  and  Ellis  conclude  that  the  chromi- 
cized membrane  is  of  decided  help  in  preventing  the  formation  of  adhesions  to 
wounded  nerves  and  tendons  when  surromided  by  contused  tissues.  They  recom- 
mend that  three  or  four  layers  of  the  membrane  be  wTapped  around  the  nerve 
or  tendon.  They  suggest  that  the  chromicized  membrane  may  be  valuable  as 
a  temporary  dura  in  brain  injuries,  but  its  value  for  this  purpose  has  not  yet 
been  demonstrated.  It  is  made  from  the  peritoneum  of  the  ox  and  prepared  in 
the  same  manner  as  catgut.  It  can  be  bought  from  reliable  manufacturers  in 
any  desired  quantity. 

Adhesive  plaster  is  a  very  valuable  aid  to  the  surgeon  in  many  ways  and,  as 
now  made  by  responsible  manufacturers,  is  clean  and  trustworthy.  The  old-time 
diachylon  plaster,  which  required  heat  to  make  it  adhesive,  has  been  almost  en- 
tirely superseded  by  rubber  adhesive  plaster  which  is  adhesive  at  all  tempera- 
tures.     The  ordinary  rubber  plaster  is  usually   bland   and   unirritating  and 


GENERAL   SURGICAL   TREATMENT.  737 

perfectly  adapted  to  surgical  uses  over  a  surgical  dressing  or  where  the  skin  is 
imbroken,  but  it  is  not  aseptic  and  is  therefore  unfit  for  application  du-ectly 
to  a  wound.  Adhesive  plaster  prepared  at  the  suggestion  of  Dr.  Lilienthal,  of 
New  York,  is  aseptic  and  especially  adapted  to  the  closure  of  wounds  in  certain 
locations.  The  ordinary  plaster  contains  impurities  and  is  destroyed  by  efforts 
at  sterilization,  but  in  the  manufacture  of  the  aseptic  plaster  the  impurities  are 
removed.  It  is  cut  into  strips  of  suitable  widths,  enclosed  in  double  envelopes, 
and  sealed  to  prevent  infection.  This  plaster  has  the  great  additional  advan- 
tage of  being  unaffected  by  moisture.  Adhesive  plaster  exposed  to  the  air  soon 
deteriorates,  but  when  kept  rolled  as  it  is  found  in  the  shops  it  will  keep  for  a 
reasonable  length  of  time.  Before  the  plaster  is  applied  the  skin  should  be  shaved, 
freed  from  grease,  and  made  perfectly  dry.  Wlien  it  is  applied  to  an  extrem- 
ity it  should  be  remembered  that  it  may  restrict  the  circulation  just  as  a  tight 
bandage  would.  Wlienever  practicable  an  adhesive-plaster  dressing  should  be 
covered  by  a  gauze  roller  bandage  which  keeps  it  clean  and  prevents  it  from 
adhering  to  clothing  or  bedding.  A  quick  removal  of  adhesive  plaster  will  give 
the  patient  the  least  annoyance.  If  it  is  adherent  to  hair  a  little  ether  will  fa- 
cilitate its  removal. 

The  uses  to  which  adhesive  plaster  are  put  in  modern  surgery  are  too  numerous 
to  mention,  but  it  may  not  be  amiss  to  call  attention  to  a  few  of  the  most  im- 
portant ones.  In  the  treatment  of  fractures  it  is  indispensable  in  the  applica- 
tion of  traction.  For  fractures  of  the  femur  the  plaster  spread  on  heavy  cloth 
called  moleskin  should  be  used  because  it  is  strong  enough  to  last  throughout 
the  treatment,  thus  saving  the  patient  the  discomfort  and  danger  of  a  change 
before  the  bone  is  united.  Sayre's  dressing  for  fractured  clavicle,  Moore's 
dressing  for  Colles'  fracture,  the  dressing  for  fractured  ribs  and  fractured  patella 
with  adhesive  plaster,  are  among  the  best  of  their  class.  Gibney's  adhesive-plas- 
ter dressing  for  a  sprained  ankle  enables  a  patient  to  get  about  much  sooner 
than  when  the  condition  is  treated  by  the  older  methods.  In  varicose  ulcers  of 
the  leg  adhesive  strapping  is  especially  beneficial.  The  dressings  of  a  stump 
after  amputation  may  be  held  in  place  by  strips  of  plaster  extending  well  up  on 
the  integument  above  the  dressing.  Dressings  applied  to  any  part  of  the  body 
can  be  held  in  place  by  adhesive  strips. 

For  an  abdominal  wound  the  adhesive  strips  answer  a  double  purpose  when 
properly  applied  over  the  dressings.  They  prevent  the  dressings  from  slip- 
ping and  give  support  to  the  wound,  thus  relieving  tension  upon  the  sutures. 
The  use  of  adhesive  strips  has  much  to  do  with  preventing  stitch  abscesses  and 
post-operative  hernias  in  present-day  surgery.  To  apply  them  successfully  re- 
quires that  they  should  be  so  adjusted  that  they  give  support  to  a  wound  with- 
out constricting  it.  For  abdominal  work  the  strips  should  be  about  one  inch 
and  a  half  wide,  and  should  begin  well  around  on  the  patient's  back  on  either 
side  and  extend  a  little  beyond  the  wound  so  that  the  ends  shall  overlap  at  the 
VOL.  I. — 47 


738  AMERICAN   PRACTICE   OF  SURGERY. 

wound.  At  the  end  next  the  wound  each  strip  should  be  folded  upon  itself  with 
adhesive  surfaces  together  so  that,  for  a  distance  of  three  or  four  inches,  the 
strip  shall  present  no  adhesive  surface.  These  ends  can  be  overlapped  and  fas- 
tened together  by  safety  pins.  They  can  be  tightened  or  loosened  at  will,  and 
they  permit  a  change  of  dressings  without  subjecting  the  patient  to  the 
discomfort  of  having  the  adhesive  straps  pulled  from  the  skin. 

Patients  who  have  undergone  an  abdominal  operation  usually  feel  the  need 
of  some  kind  of  abdominal  support.  "Wlien  the  wound  is  an  aseptic  one  this 
need  can  be  met  by  properly  applied  adhesive  strips  better  than  by  an  ab- 
dominal binder  which  is  bulky  and  which  will  not  readily  stay  in  place.  Pa- 
tients suffering  from  prolapse  of  a  kidney  or  some  other  abdominal  organ  can 
often  be  relieved  by  adhesive  strips  so  applied  as  to  render  a  surgical  opera- 
tion unnecessary.  The  improvement  in  neurasthenic  patients  with  distended 
abdomens  and  ptosis  of  all  the  abdominal  organs  following  support  of  the 
parts  by  adhesive  strips  is  sometimes  remarkable. 

Adhesive  plaster  was  used  for  the  closure  of  wounds  j^ears  ago,  but  in 
those  days  all  methods  of  wound  closure  were  less  promptly  effective  than 
they  are  to-day,  because  the  wounds  were  septic.  In  early  antiseptic  days  this 
method  could  not  be  satisfactorily  employed  because  the  dressings  were  moist; 
but,  since  the  advent  of  aseptic  surgery  with  dry  dressings  and  since  aseptic 
adhesive  plaster  is  obtainable,  it  is  quite  possible  to  close  certain  wounds  in 
this  manner.  Without  the  buried  suture,  plaster  would  rarely  meet  the  require- 
ments for  wound  closure  because  it  would  not  obliterate  dead  space  and  it 
would  have  a  tendency  to  roll  the  edges  in;  but  the  employment  of  buried  cat- 
gut sutures  in  properly  adjusting  all  the  deeper  tissues  and  obliterating  dead 
space  has  rendered  it  possible  to  close  the  integumentary  wound  by  aseptic 
adhesive  plaster,  and  this  plan  is  used  almost  to  the  exclusion  of  superficial 
stitches  by  some  surgeons.  This  method  of  wound  closure  is  only  applicable 
when  the  wound  is  perfectly  dry  and  when  it  closes  without  tension.  Under 
proper  conditions  it  insures  healing  with  the  minimum  amount  of  scar.  It  can 
be  applied  in  much  less  time  than  sutures  and  can  be  removed  easily  and  quickly. 
Nervous  patients  usually  have  an  unwarranted  amount  of  anxiety  about  the 
removal  of  the  stitches,  and  if  they  can  be  assured  that  there  are  none  to 
remove  they  are  saved  much  worry.  Adhesive  plaster  is  an  indispensable 
part  of  an  orthopedist's  armamentarium.  He  uses  it  extensively  for  adjusting 
apparatus  to  the  body  and  to  protect  the  integument  from  chafing.  It  affords 
a  very  efficient  means  of  pressure  upon  an  inflamed  joint. 

Plaster  of  Paris  in  the  form  of  plaster  bandages  is  a  valuable  surgical 
appliance.  For  ordinary  use  good  bandages  can  be  bought  already  pre- 
pared, but  when  large  quantities  are  used,  as  in  a  hospital,  it  is  much  more  eco- 
nomical to  prepare  them.  The  prepared  bandages  are  put  up  in  airtight  tin 
boxes  to  protect  them  from  moisture.     They  vary  in  width  from  two  to  four 


GENERAL  SURGICAL  TREATMENT.  739 

inches.  A  three-inch  bandage  is  a  good  width  for  general  use.  In  preparing  ban- 
dages coarse  crinohne  cloth  and  the  best  dental  plaster  only  should  be  employed. 
Cheese  cloth  is  too  heavy  and  too  closely  woven,  and  commercial  plaster  is  too 
slow-setting.  ^\11  starch  and  glue  should  be  removed  from  the  crinoline  because 
it  interferes  with  the  setting  of  the  plaster.  The  bandages  must  be  rolled 
loosely  and  should  have  the  meshes  of  the  cloth  rubbed  full  of  the  plaster  as 
they  are  rolled.  Either  an  excess  or  a  deficiency  of  plaster  makes  a  poor  band- 
age. The  bandages  must  not  be  moistened  until  everythmg  is  ready  for  their 
application.  They  should  then  be  stood  on  end  in  a  large  basin  well  filled 
with  warm  water,  one  at  a  time.  A  small  amount  of  water  soon  becomes 
so  saturated  with  plaster  that  it  will  not  soak  through  the  bandages.  Cold 
water  makes  the  plaster  harden  or  "set"  too  slowly,  and  hot  water  has  the 
opposite  effect.  "Wlien  the  air  bubbles  cease  to  arise  from  the  bandage  it  is  ready 
to  be  taken  out  of  the  water.  It  should  then  be  removed  promptly,  gently 
squeezed  in  the  hand  to  eliminate  the  excess  of  water  and  applied  as  a  roller 
bandage  is  applied,  save  that  reverses  need  not  be  made.  Each  layer  is  thor- 
oughly rubbed  with  a  moist  hand  as  it  is  applied  so  as  to  make  it  coalesce  with 
the  layer  underneath.  The  rubbing  also  takes  the  place  of  reverses  and  makes 
a  smooth  surface.  As  one  bandage  is  taken  from  the  water  another  should 
be  put  in.  If  several  are  put  in  at  once  some  are  liable  to  set  before  the  surgeon 
has  had  time  to  apply  them.  Objections  have  been  made  to  plaster  on  the 
grounds  that  it  is  too  heavy,  becomes  filthy,  and  is  difficult  to  remove.  These 
objections  can  be  applied  to  any  material  when  too  much  of  it  is  used  or  when 
it  is  improperly  applied  or  when  it  is  long  retained  in  place.  The  most  com- 
mon mistake  made  in  the  use  of  plaster  of  Paris  is  that  too  much  is  used  at  one 
time,  the  dressing  thus  being  rendered  too  heavy  and  difficult  to  remove. 
"\^^ien  good  bandages  are  properly  applied  to  an  extremity  the  splint  when  re- 
moved should  not  weigh  much  more  than  a  splint  of  heavy  pasteboard  or 
light  sole  leather.  A  heavj^  plaster  bandage  is  vmnecessary,  is  a  burden  to  the 
patient  and  a  waste  of  material,  and  is  more  difficult  to  remove  than  a  lighter 
one  of  the  same  material.  The  removal  of  a  plaster  bandage  by  unskilled 
hands    is   difficult,   but    when    properly   done    it    is   an    easy   matter.      The 


Fig.  2S2. — Plaster-Bandage  Cutter. 

plaster-cutters  on  the  market  are  not  satisfactory  and  are  quite  unnecessary. 
An  ordinary  pocket  knife  with  a  good  strong  blade  will  answer  the  purpose 
admirably,  but  a  knife  with  a  short  stout  blade  and  a  solid  metal  handle  ending 
in  a  wedge  with  which  the  edges  of  the  splint  can  be  pried  apart  is  the  best 
instrument  for  the  purpose     (Fig.  282).     To  remove  a  plaster  splint  a  strip 


740  AMERiaiN   PRACTICE   OF   SURGERY. 

about  an  inch  wide  at  the  proper  place  should  be  moistened.  This  makes  the 
plaster  soft  so  that  it  will  cut  easily.  No  solution  is  better  for  this  purpose 
than  water.  After  they  have  been  moistened,  the  fingers  of  the  left  hand 
should  grasp  the  upper  end  of  the  splint  and  lift  it  far  enough  from  the  part 
for  the  knife  to  be  applied  to  its  upper  edge.  One  side  of  the  cut  splint  should 
be  constantly  pulled  away  from  the  skin  so  that  the  knife  can  be  applied  to 
the  edge  just  as  a  shoemaker  cuts  sole  leather.  'V\Tien  the  procedure  is  carried 
out  in  this  manner  a  properly  applied  plaster  splint  can  be  removed  from  the 
whole  length  of  the  lower  extremity  in  a  brief  time,  but,  when  the  knife  is 
applied  to  the  outer  surface  of  the  splint  instead  of  the  edge,  the  m^dertaking 
is  difficult  and  tedious. 

Plaster  is  used  very  extensively  in  the  treatment  of  tuberculous  joints  to  se- 
cure rest  and  is  considered  the  best  material  at  our  disposal  by  many  surgeons. 
For  this  purpose  it  must  extend  well  above  and  below  the  diseased  joint  in  order 
to  limit  motion  as  much  as  possil^le.  For  the  treatment  of  clubfoot,  plaster  is 
undoubtedly  the  best  dressing  in  ordinary  hands.  Tlie  plaster  should  not  be  used 
to  overcome  the  deformity,  but  to  maintain  the  correct  position  after  the  defor- 
mity has  been  reduced.  If  an  effort  is  made  to  overcome  the  deformity  by  force 
after  the  plaster  is  applied,  pressure  necrosis  will  surely  follow.  When  necrosis  of 
the  integument  follows  the  application'of  the  plaster  bandage  the  fault  is  not  with 
the  material.  Pott's  disease  at  the  lower  part  of  the  spine  can  be  satisfactorily 
treated  by  the  plaster  jacket,  and,  even  in  the  hands  of  one  accustomed  to  ap- 
plying braces,  is  more  likely  to  be  efficiently  applied  than  a  steel  brace. 

For  the  treatment  of  fractures,  plaster,  properly  applied,  is  one  of  the  very 
best  retaining  materials.  It  is  easy  to  obtain  and  to  apply,  and  remains  where  it 
is  put  notwithstanding  meddlesome  patients  and  friends.  It  is  not  a  suitable 
material  where  much  contusion  is  present  and  much  swelling  is  to  be  expected. 
It  should  not  be  used  as  the  first  dressing  in  any  case  where  the  surgeon  or  his 
assistant  is  not  near  the  patient,  for  fear  of  sweUing,  but  after  a  week  or  ten  days 
it  can  be  made  a  satisfactory  dressing  for  most  fractures.  For  the  treatment  of 
compound  fractures  there  are  possibly  better  splints  than  plaster  of  Paris,  but 
in  the  hands  of  those  accustomed  to  its  use  it  is  one  of  the  best  materials  for  this 
purpose.  It  is  applied  over  the  surgical  dressing,  and  a  window  cut  to  per- 
mit treatment  of  the  woimd. 

Plaster  bandages  are  often  applied  over  a  surgical  dressing  to  keep  it  in  place 
and  to  keep  the  parts  at  rest.  For  example,  it  is  often  advantageously  applied 
after  a  hernia  operation  on  a  child. 

Rubber  goods  are  used  very  extensively  in  surgery  at  the  present  time.  Rub- 
ber gloves  have  already  been  considered  on  page  709.  Rubber  tubes  still  hold  an 
important  place  as  drainage  material,  and,  when  a  tube  of  any  kind  is  indicated, 
rhis  is  probably  the  best.  Tubes  of  a  very  small  size  are  no  better  than  strips 
of  rubber  tissue,  and  very  large  tubes  are  no  longer  used  because  they  are  unnec- 


GENERAL  SURGICAL  TREATMENT.  741 

essary.  Tubes  varying  in  size  from  that  of  an  ordinary  lead  pencil  to  that  of 
the  little  finger  will  meet  every  indication.  The  coarse  white  rubber  tubing 
of  commerce  should  not  be  used  except  in  an  emergency.  The  soft  red  or  black 
rubber  tubmg  made  purposely  for  drainage  is  the  best.  It  should  be  soft 
and  flexible,  with  walls  thick  enough  to  prevent  collapsmg,  but  not  so  thick 
as  to  make  the  calibre  of  the  tube  too  small.  It  can  be  prepared  by  boiling 
and  kept  m  a  five-per-cent  carbolic  acid  solution.  It  is  safer  to  boil  tubes 
just  before  the  operation  than  to  depend  upon  those  which  have  been  kept  in 
a  disinfecting  fluid. 

The  Esmarch  bandage,  as  originally  introduced  for  emptying  out  the  blood 
from  an  extremity  preparatory  to  a  bloodless  operation,  consisted  of  a  rubber 
webbing,  but  this  has  given  way  to  the  solid  rubber  bandage  known  as  Martin's 
bandage.  Most  of  the  Martin  bandages  foimd  in  the  instrument  stores  are  apt 
to  be  practically  worthless  for  the  purpose  for  which  they  are  intended  because 
they  are  of  too  light  weight.  They  are  too  frail  to  force  the  blood  out  of  a 
large  extremity  and  they  break  easily.  A  good  rubber  bandage  for  this  pur- 
pose should  be  as  thick  as  blotting  paper  and  three  or  four  inches  wide.  It 
can  be  boiled,  or  prepared  for  use  in  carbolic  solution. 

Rubber  tissiie  is  used  in  surgery  for  drainage,  to  cover  skin  grafts,  and  to 
cover  a  damp  surgical  dressing  and  keep  it  moist.  \^nien  very  little  drainage  is 
recjuired  a  small  strip  of  rubber  tissue  answers  the  purpose  admirably.  It  is 
very  extensively  used  for  surrounding  gauze  drains  to  prevent  them  from  ad- 
hering to  the  tissues.  After  skin  grafting  the  rubber  tissue  is  cut  into  strips  and 
laid  over  the  grafts  like  the  shingles  on  a  roof.  This  permits  the  discharges 
to  escape  into  the  gauze  dressings  applied  over  them  and  prevents  the  gauze 
from  adhering  to  and  destroymg  the  grafts.  Rubber  tissue  cannot  be  boiled 
because  the  heat  destroys  it.  It  can  be  prepared  by  washing  in  soap  and 
water,  rinsing  in  clear  water,  and  being  placed  in  a  1  : 1,000  solution  of  bi- 
chloride. The  water  in  which  it  is  washed  cannot  be  very  warm  or  the  tissue 
will  adhere  to  itself  and  be  destroyed.  The  bichloride  solution  should  be 
changed  at  least  once  in  two  weeks  and,  just  before  using,  the  tissue  should  be 
immersed  in  a  sterile  salt  solution  to  remove  the  bichloride.  Rubber  tissue 
cannot  be  kept  satisfactorily  in  a  carbolic  solution  because  it  is  softened  there- 
by, and  becomes,  when  it  is  in  this  condition,  adhesive  and  inconvenient  to 
handle. 

INSTRUMENTS. 

A  yoimg  practitioner  just  purchasing  his  first  supply  of  instruments  wlU 
find  it  more  economical  and  in  every  way  more  satisfactory  to  buy  only  such 
as  are  necessary  to  meet  his  requirements,  and  then  later  to  add  to  this  stock 
as  his  needs  arise.  Always  buy  the  very  best  quality,  since  they  are  more 
economical  in  the  end  and  serve  their  purposes  better. 


742 


AMERIC-IX   PRACTICE   OF   SLTIGERY. 


Instrmiients  should  be  smooth  m  finish  and  should  be  made  of  metal  tln-ough- 
out,  only  the  best  of  material  being  used.  The  beautiful  pearl,  ivory,  ebony, 
tortoise-shell,  and  wooden  handles  so  much  in  vogue  at  one  time  are  no  longer 
used  because  they  readilj- become  infected  and  cannot  be  sterilized  without  injury. 
Nickel-plating  keeps  instruments  from  rusting,  but  should  never  be  applied  to 
cutting  instruments.  An  uistrmnent  should  never  be  made  heavier  than  is 
necessar}-  to  give  it  the  requisite  strength,  for  hght  instruments  are  conducive 
to  delicate  work.  Too  long  an  instrmnent  is  a  mechanical  disadvantage  as 
it  keeps  the  operator's  hand  too  far  away  from  the  field  of  operation.  The 
nearer  the  hand  is  to  the  wound  the  quicker  and  more  accurate  the  move- 
ments. Most  scissors,  haemostatic  forceps  and  clamps  are  now  so  constructed 
that  they  can  be  readilj-  taken  apart  when  being  cleaned,  but  a  screw  lock  is 
much  lietter  for  scissors  and  hajmostats  because  it  can  be  tightened  as  it  becomes 


Fig.  2S3. — A  Verv  Good  Pattern  of  Knife ;  small  blade  and  smooth  metal  handle. 


worn.  Simplicity  hi  construction  is  a  commendable  feature  in  an  instrument. 
Complicated  in.struments  made  for  special  operations  are  to  be  avoided  when 
the  work  can  be  properly  done  with  ordinary  instruments.  It  is  too  much 
the  tendency  among  instrument  makers  and  young  sirrgeons  to  invent 
new  mstrmnents  or  change  old  ones.  One  who  allows  himself  to  purchase 
the  wonderful  things  presented  l)y  the  travelling  instrument  dealer  wUl  soon 
ha^■e  his  instriunent  case  filled  with  a  lot  of  worthless  implements.  There 
are  a  few  special  instruments  that  are  almost  mdispensable,  but  as  com- 
pared with  the  number  offered  for  sale  they  are  very  few  mdeed.  It  is  a  mistake 
to  have  too  many  instruments  prepared  for  an  operation,  as  comparatively  few 
are  ever  used,  and  the  rest  are  only  in  the  way  and  are  deteriorated  by  boil- 
ing. Every  surgeon  has  his  favorite  instruments  with  which  he  becomes 
specially  dexterous.  The  good  sm'geon  depends  upon  his  experience  and  skilled 
hands  to  enable  him  to  do  good  work  with  whatever  instrmiients  may  be 
present  in  an  emergency.  Instruments  should  be  kept  in  good  repair,  because 
a  dull  cutting  instrument  bruises  the  tissues  and  makes  the  surgeon's  efforts 
slow  and  micertain,  and  a  forceps  that  does  not  bite  true  or  lets  go  is  always 


GENERAL  SURGICAL  TREATMENT. 


743 


disturbing  and  sometimes  dangerous.  It  is  bad  taste  to  make  an  unnecessary 
display  of  instruments.  Bright,  clean-looking  instruments  will  surely  make  a 
better  impression  than  black,  dirty-looking  ones.  The  surgeon  or  the  institu- 
tion using  instruments  until  they  become  rusty  or  black  should  have  duplicates, 
so  that  one  set  can  be  repaired  or  polished  while  the  other  is  in  use.  This  is  really 
a  matter  of  economy,  for  an  instrument  properly  cared  for  will  last  much  longer 
than  one  that  is  neglected. 

Knives. — A  good  sharp  knife  is  very  essential  for  quick,  smooth  operating. 


Fig.  284.— Various  Patterns  of  Surgical  Scissors.     With  this  assortment  all  the  conditions  in  general 
surgery  can  be  met. 

It  should  have  a  blade  of  the  very  best  steel  and  a  smooth  metal  handle  of 
sufficient  weight  to  balance  well  in  the  hand.  The  blade  should  be  compara- 
tively small  and  bellied  or  convex  on  the  cutting  edge.  Wlien  it  is  too  long 
it  cannot  be  so  skilfully  handled,  and  length  is  never  necessary  except  in  larger 
amputating  knives,  because  the  cutting  is  all  done  by  a  portion  of  the  blade  near 
the  point.  The  handle  should  be  so  shaped  that  it  can  be  used  as  a  blunt  dis- 
sector when  necessary  (Fig.  283).     Knives  should  always  be  cared  for  by  some 


JU 


AMERICAN   PRACTICE   OF   SURGERY. 


one  connected  ■nith  the  operating-room,  so  that  they  may  always  be  in  order. 
It  is  dangerous  to  use  a  dull  knife,  and  then  -nithout  warning  employ  a  sharp 
one. 

Scissors. — Xext  to  knives,  scissors  are  the  most  important  cutting  instru- 
ments. Thej-  too  should  be  of  thever3'best  steel  and  should  be  kept  sharp.  The 
blades  should  be  united  hj  a  screw  pivot  which  shotild  be  kept  tight  enough 
to  keep  the  edges  in  proper  relation  with  each  other  (Fig.  284).  Infection  and 
consequent  failure  of  union  may  be  caused  b}'  necrotic  tissue  that  owes  its 
origin  to  the  pinching  of  dull  or  loose-jointed  scissors.  Scissors  should  not 
be  nickel-plated.  Boiling  duUs  them  and  eventuaUj-  spoils  them.  They  are 
made  in  shapes  and  sizes  too  numerous  to  mention,  but  with  a  small  assort- 


FiG.  2S5. — Various  Kinds  of  Xeedles  for  Surgical  Purposes.  1,  Cutting  point,  for  integument; 
2,  round  point,  for  use  in  operations  upon  the  intestine;  3,  saddler's  needle,  for  integument;  4,  5,  6, 
and  7,  roimd-pointed,  for  intestine  and  peritoneum  ;  S  and  9,  needles  with  a  cutting  edge,  for 
integmnent,  muscle,  and  mucous  membrane.  The  cvured  needles  are  all  flat  on  the  concave  and 
convex  sides  and  have  eyes  large  enough  to  take  catgut  suture  thread. 


ment  of  medium-sized  straight  and  curved  scissors  most  requirements  can  be 
met.  It  is  usually  in  deep  wounds  with  dense  tissues  that  the  large  blunt- 
pointed  varieties  are  needed. 

Needles. — The  half-curved  cutting-edged  needle  so  common])'  used  twenty- 
five  years  ago  is  rarely  used  now,  the  straight  and  fuU-curved  needle  ha\Tng 
taken  its  place.  The  straight  needle  is  alwaj-s  to  be  preferred  when  applica- 
ble, because  it  does  not  turn  in  the  fingers  or  needle-holder  and  the  operator 
knows  where  the  point  is  located.  For  the  integmnent,  for  intestinal,  and  for 
stomach  work  a  straight  needle  is  better,  while  for  deep  woimds  and  plastic 
work  some  form  of  curved  needle  is  preferable.  For  intestinal  sewing  the  point 
of  the  needle  should  be  rotmd  like  the  ordinar}'  cambric  needle,  Isut  for  the 
integument  it  should  be  spear-pointed  or  have  cutting  edges  like  the  saddler's 
needle.     The  curved  neecUe  is  usually  made  with  too  much  cutting  edge.    If  the 


GENERAL  SURGICAL  TREATMENT.  745 

needle  has  a  sharp  point  with  a  cutting  edge  extending  half  an  inch  from  the 
point  it  will  perforate  the  tissues  readily  and  will  not  cut  the  operator's  fingers. 
For  peritoneal  work  the  curved  needle  should  have  a  round  point  without  a 
cutting  edge.  Every  curved  needle,  except  the  large  ones  intended  for  apply- 
ing through-and-through  sutures,  should  have  an  eye  large  enough  to  be 
threaded  with  catgut  of  a  medium  size.  It  should  be  flattened  on  both  the 
concave  and  convex  sides  for  some  distance  from  the  eye  so  that  it  can  be  held 
securely  in  the  needle-holder.  A  curved  needle  that  is  round  throughout  its 
length  except  at  the  eye  is  unreliable  and  unsafe  and  should  never  be  bought. 
It  is  unreliable  because  it  is  liable  to  turn  in  the  holder  at  a  critical  moment, 
and  imsafe  because  when  it  turns  it  may  puncture  an  important  part.  It  is 
also  very  liable  to  break  because  the  operator  is  apt  to  grasp  the  eye  in  the 


Fig.   286. — A  Very  Satisfactory  Form  of  Needle-Holder. 

holder  and  to  apply  greater  pressure  than  the  needle  can  withstand  in  his  efforts 
to  hold  it  securely  (Fig.  285). 

Needle- Holders. — A  perfectly  satisfactory  needle-holder  has  not  yet  been  made. 
This  is  proven  by  the  fact  that  new  ones  are  constantly  being  designed.  The 
requirements  of  a  needle-holder  are :  that  it  shall  not  be  bulky  and  heavy ;  that 
its  catch  shall  be  simple  in  construction  and  easy  to  work :  that  it  shall  hold  the 
needle  firmly  without  breaking  it;  and  that  its  jaws  be  so  constructed  that  the 
point  of  a  needle  can  be  quickly  grasped  after  it  has  been  passed  through  the 
tissues  so  as  to  draw  the  needle  and  thread  through.  Every  surgeon  becomes 
accustomed  to  one  of  the  many  varieties,  but  he  always  expects  a  certain  amount 
of  annoyance  and  inconvenience  from  it  and  is  usually  ready  to  try  another 
which  appears  to  be  an  improvement.  Many  of  the  faults  attributed  to  the 
needle-holder  are  really  due  to  improperly  shaped  needles.  A  curved  needle 
which  is  round  throughout  its  length  cannot  be  properly  held  by  a  fiat- jawed 
holder,  and  on  the  other  hand  a  holder  which  requires  that  the  needle  fit  a  cer- 


746  AMERICAN  PRACTICE-  OF  SURGERY. 

tain  notch  in  its  jaws  causes  the  wasting  of  much  \'akiable  time.  Round 
curved  needles  flattened  near  the  eye  are  very  well  controlled  by  a  flat- jawed 
needle-holder.  A  beginner  or  one  not  wedded  to  some  other  variety  will  find 
the  flat-jawed  instrument  represented  in  the  accompanying  cut  (Fig.  286)  very 
satisfactory.  Some  years  ago  the  writer  suggested  that  the  notched  jaws  of  a 
McBurney  needle-holder  be  replaced  by  flat  copper  plates  and  that  the  Hage- 
dorn  catch  be  substituted  for  the  simple  spring;  and  the  holder  here  illus- 
trated is  the  result.  The  jaws  are  lined  with  heavy  copper  plates  which  render 
less  liable  the  breaking  of  the  needle  and  afford  a  firmer  grasp.  The  spring 
catch  is  controlled  by  the  little  finger,  and  after  a  time  one  is  unconscious  of  any 
effort  to  work  it.  It  is  made  in  three  sizes  and,  with  properly  flattened  needles, 
works  very  well.     The  most  serious  objection  to  this  instrument  is  that  the 


Fig.  2S7.— Haemostatic  Fig.  2SS.— Kelly's  Fine-Pointed 

Forceps  Haemostatic  Forceps. 

copper  plates  wear  out  and  must  be  renewed.     If  properly  flattened  needles 
were  always  at  hand  the  copper  plates  could  be  dispensed  with. 

Hcemostatic  Forceps. — Asepsis  has  made  modern  methods  of  hamostasis 
possible.  Formerly  surgeons  caught  a  bleeding  vessel  with  a  tenaculum  or  an 
anatomic  forceps  and,  after  carefully  isolating  it,  tied  a  silk  thread  aroimd  it 
and  left  the  end  of  the  thread  hanging  out  of  the  woimd.  In  an  aseptic  wound 
it  is  not  strictly  necessary  to  isolate  any  but  the  larger  vessels.  Small  bleeding 
points  are  grasped  en  masse  and  tied  with  an  aseptic  ligature,  and  the  ligature 
is  cut  short.  For  this  purpose  we  have  haemostatic  forceps  with  scissor  han- 
dles and  a  catch  which,  when  locked,  holds  until  loosened.  This  makes 
very  rapid  work  possible  without  the  loss  of  blood,  as  forceps  can  be  ap- 
plied and  left  tmtil  the  operator  is  ready  to  tie  the  vessel.  The  temporary 
pressure  made  by  the  forceps  will  control  the  hemorrhage  from  most  small  ves- 
sels so  that  no  ligature  will  be  required.  The  exact  shape  of  the  forceps  is 
immaterial,  but  it  should  not  be  too  long  or  too  heavy.  It  should  have  a  small 
point  and  a  reliable  catch.    They  are  usually  made  with  a  French  lock  and  may 


GENERAL  SURGICAL  TREATMENT. 


747 


therefore  be  taken  apart  for  cleaning,  but,  since  tlaey  are  always  sterilized  by 
boiling,  the  screw  pivot  is  better  because  the  French  pivot  soon  becomes  worn 
and  loose  and  cannot  be  easily  repaired.  When  the  point  is  too  large  it  grasps 
too  much  tissue  and  the  artery  cannot  be  so  securely  tied.  An  unnecessary  mass 
of  strangulated  tissue  is  objectionable  in  a  wound  because  it  may  become  ne- 
crotic and  the  home  of  bacteria.  Figs.  287  and  288  represent  very  good  varieties 
of  artery  forceps.     It  is  an  advantage  to  have  a  few  forceps  curved  at  the  end 


Fig.  2S9. — Curved  Haemostatic  Forceps 


Fig.  290. — Kocher's  Forceps. 


as  represented  by  Fig.  289.  A  forceps  that  does  not  meet  properly  at  the  point, 
or  which  loosens  after  being  applied  to  a  vessel,  should  be  repaired  or  thrown 
away,  as  it  is  unsafe.  A  few  Kocher  forceps  of  medium  size  (Fig.  290)  are  a 
great  help  in  carefully  holding  the  tissues,  but  are  not  as  good  as  the  other 
varieties  for  catching  a  bleeding  vessel. 

Ligature  Carriers. — A  ligature   carrier   is   a  very   valuable   instrument   in 
abdominal  surgery.     Most  of  those  in  use  are  modifications  of  the  Deschamps 


Fig.   291. — Blunt  Ligature  Carrier. 


needle,  the  most  important  change  being  from  the  sharp  point  and  cutting 
edge  to  a  blunt  point  and  edge.  They  are  made  right  and  left,  but  a  surgeon 
usually  needs  but  one  (Fig.  291). 

The  Cleveland  ligature  carrier  (Fig.  292)  is  a  very  convenient  mstrument. 
It  economizes  time  and  material  because  it  has  no  eye  to  be  threaded  and 
because  the  ligature  can  be  caught  at  the  extreme  end  and  is  more  likely  to  be 
tied  without  waste. 


748 


AMERICAN  PRACTICE  OF  SURGERY. 


Retractors. — Retractors  are  often  necessary,  but  they  are  also  often  used 
too  much  and  too  harshly.  Many  injuries  have  been  caused  by  these  instru- 
ments, when  the  patient  was  unconscious,  that  would  not  have  occm-ed  dui-ing 
consciousness.  A  very  important  part  of  a  surgeon'  sduty  toward  his  patient  is 
to  see  that  he  is  properly  protected  from  injury  of  all  kinds  when  helpless  from 


Fig.  292. — Cleveland's  Ligature  Carrier. 

the  anaesthetic,  and  one  of  the  common  injuries  to  which  he  is  subject 
is  that  caused  by  improperly  constructed  or  unskilfully  handled  retractors.  The 
sharp-pointed  retractors  should  rarely  be  used  except  when  applied  to  some  tissue 
which  is  to  be  removed,  because  they  lacerate  the  tissues.  Smooth  retractors 
(Fig.  293)  of  A^arious  sizes  will  meet  nearly  every  indication.     The  self-retain- 


FiG.  293.— Langenbeck's  Blunt  Retracto 


ing  abdominal  retractor  (Fig.  294)  is  a  very  helpful  instrument.  The  amount 
of  pressure  made  by  it  can  be  regulated  by  the  one  who  applies  it.  It  should 
be  remembered  that  this  or  anj^  other  retractor  will  damage  the  tissue  ^^"hen 
applied  with  too  great  force  or  for  too  long  a  time.  The  special  advantage 
of  this  instrument  is  that  it  takes  the  place  of  two  hands,  thus  reducing  the 


GENERAL  SURGICAL  TREATMENT. 


749 


nimiber  of  assistants,  which  is  ah^ays  an  advantage.     The  handles  rest  over 
the  patient's  thighs,  out  of  the  surgeon's  way.- 

Nails  and  ^reiys.— Nails  and  screws  have  been  extensively  used  in  the 
treatment  of  fractures  and  after  excisions,  but  they  have  not  proven  ^'ery  satis- 
factory because,  in  spite  of  every  precaution,  they  often  prove  troublesome. 
"Wlren  allowed  to  protrude  through  the  skin  they  are  almost  certain  to  cause 
local  pressure  necrosis  and  infection,  which  in  turn  lead  to  suppuration.     When 


Fig.  294. — Self-Retaining  Abdominal  Retractor;  takes  the  place  of  one  assistant. 


they  are  buried  the  results  are  more  satisfactory,  but  even  then  they  are  prone  to 
act  as  foreign  bodies  at  a  later  period,  causing  necrosis  and  abscess,  which 
necessitate  their  removal.  As  a  means  of  approximating  the  bones  after  exci- 
sion of  the  knee  they  have  been  superseded  by  chromicized  catgut  sutures. 
In  the  treatment  of  fractures  they  still  have  a  limited  field  of  usefulness,  but 
even  here  the  chromicized  catgut  suture  is  superior  in  the  vast  majority  of 
cases  because  it  holds  the  fragments  more  securely  and  becomes  absorbed 
later.     A  nail  or  screw  has  in  reality  a  very  insecure  hold  on  a  bone  because 


750  AMERICAN  PRACTICE  OF  SURGERY. 

it  is  only  the  outer  compact  la}'er  which  affords  any  special  security,  and  even 
this  hold  loosens  very  soon.  Fragments  fastened  in  this  way  with  seeming 
security  will  usually  be  found  to  have  loosened  after  ten  or  twelve  days.  The 
elastic  catgut  allows  of  a  little  play  from  the  first,  but  the  elasticity  does  not 
increase  dm-ing  the  life  of  the  gut.  The  slender,  small-headed  steel  nails  and  the 
screws  of  commerce  are  satisfactory  for  this  purpose.  They  can  be  silver- 
plated  at  a  trifling  expense,  and  this  renders  them  less  liable  to  corrode  or 
irritate.     They  should  be  sterilized  by  boiling. 

APPLICATION  OF  THE  PRINCIPLES. 

Fads  Not  Principles. — During  the  development  of  our  present  technique 
fads  have  often  been  mistaken  for  principles.  Certain  things  ha-\-e  been  done 
that  would  have  been  better  left  undone.  Poisonous  powders  and  solutions  were 
used  in  spite  of  the  fact  that  their  use  was  not  justified  by  careful  bacteriologic 
findings.  As  the  truth  has  dawned  upon  us  we  have  learned  that  good  results 
were  obtained  in  spite  of  these  things  rather  than  by  virtue  of  them.  Doubtless 
we  have  yet  much  to  learn,  but  the  fact  that  the  teclinique  has  steadih'  grown 
more  simple  proves  that  we  are  freer  from  fads  and  nearer  to  principles.  A 
scientific  principle  is  based  upon  scientific  facts  and  is  capable  of  demonstra- 
tion, but  in  surgery  we  have  the  element  of  life  to  deal  with  which  often  inter- 
feres with  a  demonstration  of  what  clinically  seems  to  be  a  fact.  The  real  prin- 
ciples of  surgery  and  of  modern  wound  treatment,  however,  are  scientific  facts 
capable  of  demonstration.  We  are  prone  to  run  after  fads  because  we  have 
been  much  given  to  empiricism.  Many  of  om-  fads  have  been  excusable  because 
we  were  doing  many  new  things  and  results  were  constantly  improving.  The 
consequence  was  that  some  of  the  things  done  were  given  undeserved  credit. 
It  would  seem  a  simple  matter  to  eliminate  a  useless  procedure  by  comparing 
the  results  obtained  in  a  series  of  cases  with  this  procedure,  with  those  of  another 
series  in  which  the  procedure  was  not  used,  but  different  observers  often  arrive 
at  diametrically  opposite  conclusions  from  what  are  seemingl}'  the  same  prem- 
ises. Since  we  have  scientific  principles  to  work  upon  we  should  be  slow  to 
accept  of  anything  based  upon  empiricism. 

Bloodless  Surgery. — This  is  a  term  which  has  a  great  attraction  for  the 
laity  and  for  professional  men  who  lack  confidence  in  their  ability  to  secure 
the  aseptic  healing  of  a  woimd.  It  received  great  impetus  a  few  years  ago  when 
an  eminent  foreign  surgeon  came  to  this  country  to  demonstrate  his  bloodless 
method  for  treating  congenital  dislocation  of  the  hip.  The  so-called  bloodless 
operation,  however,  with  due  deference  to  its  real  merit,  is  often  bloody  and 
attended  with  severe  injury. 

The  subcutaneous  tenotomy  of  superficial  tendons  is  a  good  operation 
because  the  parts  are  superficial  and  the  surgeon  knows  what  he  is  doing,  and 


GENERAL  SURGICAL  TREATMENT.  751 

it  leaves  a  small  scar,  but  be3'ond  this  the  field  for  bloodless  surgery  is  limited 
in  application. 

Wounds. — The  manner  in  which  a  wound  is  made  has  much  to  do  with  its 
healing.  A  wound  made  with  a  sharp  instrument  will  heal  more  quickly  and 
certainly  than  one  made  with  a  dull  one.  Wlien  possible  an  operation  wound 
should  always  be  made  in  the  natural  line  of  cleavage,  passing  either  between 
muscles  or  through  them  parallel  with  their  fibres.  When  muscles  are  split, 
the  splitting  should  be  done  with  an  instrument  sharp  enough  to  separate  the 
fibres  without  lacerating  or  bruising  them.  The  conscientious  surgeon  will  al- 
ways handle  the  tissues  of  an  unconscious  patient  as  carefully  as  he  would  those 
of  a  conscious  one.  The  preservation  of  the  nerve  supply  is  much  more  impor- 
tant than  the  preservation  of  the  blood  supply,  because  nature  under  all  ordi- 
nary conditions  very  quickly  restores  the  latter,  while  she  often  fails  to  restore 
the  former,  the  consequence  being  atrophy  and  paralysis.  Many  ventral  hernias 
are  due  to  mjury  to  the  muscular  nerve  supply,  not  only  from  paralysis,  but 
also  from  trophic  changes. 

The  Treatment  of  Wounds. 

In  considering  the  application  of  the  principles  underlying  wound  treatment  it 
is  unnecessary  to  dwell  upon  the  usual  classification  of  wounds,  but  it  is  necessary 
to  take  up  separately  aseptic,  suspected,  and  infected  wounds,  because  there  is  a 
difference  in  the  application  of  the  principles  under  these  different  conditions. 

Aseptic  Wounds. — The  treatment  of  an  operative  wound,  which  we  take  as  a 
type  of  an  aseptic  woimd,  should  begin  hours  or  days  before  it  is  made,  and  end 
when  it  is  completely  healed — i.e.,  when  the  stitches  have  been  removed  and  the 
dressings  are  no  longer  needed.  The  stimulation  of  the  patient's  excretions,  the 
cleansmg  of  his  skin,  the  preparation  of  the  surgeon's  hands,  instrmnents,  ligatures, 
and  dressings,  are  aU  essential  parts  of  wound  treatment  which  enable  the  modern 
surgeon  to  secure  primary  healing.  Old-time  surgeons  were  better  anatomists 
and  often  more  skilled  operators  than  modern  sm-geons,  but  the  tyro  in  surgery, 
by  the  use  of  modern  methods,  can  secure  better  results  than  the  old-time 
surgeons  dared  to  hope  for,  and  can  invade  portions  of  the  body  then  con- 
sidered beyond  the  domain  of  surgery.  This  wound  treatment  has  resulted 
in  the  transfer  of  many  diseases  formerly  considered  exclusively  medical,  to 
the  domain  of  surgery.  It  is  the  outgrowth  and  travelling  companion  of  the 
science  of  bacteriology.  It  is  a  promoter  of  modern  pathology,  because  many 
important  discoveries  in  pathology  are  based  upon  the  knowledge  of  living 
tissues  made  possible  by  aseptic  surgery.  Pathologists  groped  through  the 
abdomens  of  dead  subjects  for  centuries  without  discovering  that  appendicitis, 
salpingitis,  and  gall  stones  are  the  causes  of  many  pathologic  conditions  within 
the  abdomen.  Modern  wound  treatment  has  helped  to  raise  surgery  to  a  dis- 
tinct science.     If  these  facts  be  taken  into  consideration  is  it  strange  that 


752  AMERICAN   PRACTICE   OF  SURGERY. 

so  much  time  is  spent  upon  the  teaching  of  the  underl}'ing  principles  of  sur- 
gery, or  that  the  practice  of  surgery  based  upon  these  principles  attracts  so 
many  of  the  brightest  minds  of  rising  generations?  One  who  enters  the  profes- 
sion of  medicine  without  a  thorough  knowledge  of  the  principles  underl5ang  the 
treatment  of  wounds  can  never  hope  to  compete  with  one  who  has  that  knowl- 
edge; and  one  who  is  careless  in  putting  these  principles  into  practice  is  sure 
to  fall  by  the  wayside. 

Throughout  the  treatment  of  the  wound  the  surgeon's  efforts  should  be  to 
assist  nature  in  every  way  possible  in  her  warfare  against  bacteria,  and  to 
give  her  such  mechanical  aids  as  will  promote  and  supplement  the  natural  bio- 
logic processes.  The  term  primary  vmion  has  no  direct  reference  to  the  time 
required  for  union,  but  is  used  to  designate  an  uninterrupted  aseptic  process 
from  beginning  to  end.  The  time  required  for  this  process  depends  largely 
upon  the  perfection  of  the  surgeon's  work.  Nature  repairs  the  tissues  by  the 
interposition  of  a  layer  of  new  tissue  of  greater  or  less  thickness,  depending 
upon  how  closel}''  the  severed  tissues  are  approximated;  the  closer  and  more 
accurately  they  are  approximated  the  less  the  time  required  to  complete  the 
process.  Every  tissue  is  formed  from  cells  of  its  ov^m  kind;  and  in  order  to  se- 
cure perfect  healing  each  layer  of  tissue  must  be  closely  approximated,  muscle 
to  muscle,  tendon  to  tendon,  skin  to  skin.  Connective  tissue,  as  its  name  implies, 
is  fomid  everywhere  between  tissues,  and  when  milike  tissues  are  brought  to- 
gether they  are  united  by  connective  tissue  and  the  healing  is  not  ideal. 

The  suturing  of  loounds  is  the  most  important  mechanical  aid  to  wound  healing 
at  the  surgeon's  command.  Sutures  have  long  been  employed  in  surgery,  but  it 
is  only  since  the  introduction  of  the  aseptic  suture  that  the  surgeon  has  been  able 
to  bring  the  opposite  edges  of  each  layer  of  tissue  accurately  together.  In 
every  womad  of  any  considerable  depth  the  tier  suture  by  means  of  catgut,  sup- 
ported by  stay  sutures  of  silkworm  gut  or  some  other  unabsorbable  material, 
is  an  approved  method  of  wound  closure.  Every  careful  surgeon  takes  ample 
time  to  close  his  wounds  accurately  because  he  knows  that  much  of  his  success 
depends  upon  it.  In  closing  an  abdominal  wound,  for  example,  after  perfect 
hffimostasis,  the  peritoneum  should  first  be  closed  with  fine  catgut.  Stay  sutures 
of  silkworm  gut  should  next  be  introduced,  beginning  on  the  integument  half 
an  inch  or  more  away  from  the  wound  and  extending  through  all  the  tissues 
except  the  peritoneum.  One  stay  suture  for  every  inch  and  a  half  of  wound 
is  ample,  and  in  short  muscle-splitting  woimds,  as  for  an  exploratory  coeliotomy 
or  an  interval  appendectomy,  these  sutures  are  entirely  unnecessary.  These  stay 
sutures  should  not  be  tied  imtil  all  other  sutures  are  placed.  The  tendency  at 
the  present  time  is  to  abandon  the  through-and- through  sutures  altogether,  but 
when  they  are  properly  adjusted  the  only  objection  to  them  is  that  they  are  made 
of  unabsorbable  material  which  must  be  removed.  They  are  an  extra  safeguard 
against  accident.     They  can  be  safely  remo^'ed  on  the  eighth  or  tenth  day. 


GENERAL  SURGICAL  TREATMENT.  753 

When  muscles  have  been  cut  across  they  should  be  approximated  b}^  catgut 
sutm-es;  but  \^'hen  muscle  fibres  have  been  separated  by  splitting  they  require 
no  sutui-es,  as  the  stay  sutures  are  all  that  are  necessary.  The  fascia  of  the 
external  oblique  is  then  carefully  approximated  by  a  running  catgut  suture, 
and  next  the  integumentary  wound  is  closed  by  a  running  lock  stitch  made  of 
silk,  horsehair,  or  catgut.  Finally  the  silkworm  sutures  are  tied.  The  tying 
of  these  sutures  is  important.  The  knot  should  never  be  over  the  wound,  but 
at  one  side,  and  should  not  be  too  tight.  All  beginners  and  too  many  older 
surgeons  are  apt  to  tie  stitches  too  tightly.  Before  they  are  tied  both  ends  should 
be  well  pulled  up  so  as  to  straighten  out  the  thread,  and  then  the  knot  should 
be  tied  tightly  enough  to  give  support  to  the  buried  sutures.  These  sutures 
should  not  be  expected  to  do  more  than  to  act  as  a  reserve  support  when  for 
any  reason  union  is  delayed  beyond  the  life  of  the  catgut,  or  where  an  extra 
force  is  applied  to  the  wound  as  in  severe  vomiting.  When  sutures  sink  deeply 
into  the  tissues  so  that  the  edge  of  the  wound  looks  like  the  edge  of  a  saw  with 
blunted  teeth,  they  are  too  tight  and  are  very  liable  to  cause  pressure  necrosis 
and  abscess.  On  account  of  the  slight  swelling  which  follows  every  wound 
the  tendency  is  for  sutures  to  become  tighter  instead  of  looser,  and  there  is  no 
excuse  for  tying  them  too  tightly. 

Although  catgut  is  not  always  a  reliable  suture  material  for  an  external 
wound,  when  but  one  row  of  stitches  is  used,  it  is  coming  more  and  more  into 
use  as  an  integumentary  suture  when  the  tier-suture  method  is  employed. 
The  borders  of  the  integument  when  properly  approximated  adhere  quickly, 
and  when  the  wound  has  been  closed  without  tension  the  finest  catgut  thread 
is  excellent  material  for  eft"ecting  a  closure.  The  fine  gut  lasts  long  enough  to 
perform  its  function,  and  does  not  have  to  be  removed,  which  is  a  very  great 
advantage.  The  iodine  catgut  seems  to  be  well  fitted  for  this  purpose,  as 
clinical  experience  and  experiment  prove  that  it  is  very  difficult  to  infect. 
The  running  lock  stitch  or  buttonhole  stitch,  made  by  looping  the  thread  over 
the  point  of  the  needle  each  time  it  emerges  from  the  tissues,  is  recommended 
by  many  because  it  is  elastic,  gives  uniform  support  to  the  wound  instead  of 
making  undue  pressure  in  spots,  and,  when  silk  or  horsehair  is  used,  it  is  easily 
removed. 

Stitch  abscesses,  at  one  time  common  in  abdominal  surgery,  are  rarely  seen 
now.  This  improvement  is  not  due  entirely  to  a  greater  degree  of  cleanliness,  but 
to  other  beneficent  measiu-es.  They  were  caused  by  the  tlirough-and-through 
stitches  whicli,  unassisted,  were  given  control  of  the  tendency  of  the  wound  to 
gape,  and  which  stitches  were  commonly  tied  too  tight.  With  the  continuous 
catgut  suture  applied  to  each  layer,  the  through-and-through  sutures  have  but 
little  weight  to  carry,  and  there  is  no  excuse  for  tying  them  too  tightly.  The 
bacteria  in  the  deeper  layers  of  the  skin  will  cause  no  abscess  except  in  the 
presence  of  necrotic  tissue  or  of  independent  infection. 


754  AMERICAN  PRACTICE  OF  SURGERY. 

Before  the  wound  is  closed,  chemicals  in  the  form  of  solutions  or  powders 
should  not  be  used,  because  they  interfere  with  union.  After  closure  the  parts 
should  be  cleared  of  all  blood  by  a  piece  of  moist  gauze  and  then  thoroughly 
dried.  Several  layers  of  dry  sterile  gauze  should  first  be  applied,  and  over 
this  should  be  placed  a  liberal  layer  of  sterile  absorbent  cotton.  The  gauze 
quickly  absorbs  any  moisture  that  may  escape  from  the  wound  and  keeps  it 
dry.  The  cotton  protects  the  wound  from  injury  and  excludes  bacteria.  In 
an  abdominal  wound,  or  in  other  parts  of  the  body  where  a  roller  bandage 
cannot  be  accurately  applied,  the  dressings  should  be  held  in  place  by  adhesive 
strips,  which  not  only  keep  the  dressings  from  slipping  and  exposing  the  wound, 
but  help  to  support  the  parts  and  prevent  tension  upon  the  stitches.  For 
abdominal  wounds  the  many-tailed  bandage  should  be  snugly  applied  and  well 
pinned  over  the  dressings.  It  should  be  carefully  adjusted  so  that  the  pressure 
and  support  are  everywhere  uniform.  It  also  helps  to  hold  the  dressings  in 
place  and  to  support  the  wound.  When  properly  applied  it  is  a  great  comfort 
to  the  patient.  For  wounds  of  the  extremities  and  other  parts  of  the  body 
the  roller  bandage  is  preferable.  A  tight  bandage  is  always  a  source  of  dis- 
comfort to  the  patient  and  is  never  necessary.  In  applying  a  dressing  to  a 
wound  in  the  middle  of  an  extremity  it  should  never  be  applied  so  tightly  as 
to  necessitate  the  bandaging  of  the  whole  extremity  to  prevent  swelling.  In 
case  of  fracture  it  maj'  be  necessary  to  bandage  the  whole  extremity  because 
of  the  effects  of  hemorrhage  and  effusion  underneath  the  skin.  If  the  patient 
be  a  child  it  is  often  wise  to  apply  a  plaster-of-Paris  bandage  over  the  dressing. 
Dressings  properly  applied  to  an  aseptic  wound  rarely  need  to  be  changed  until 
about  the  eighth  day,  when  the  stitches  are  removed. 

Rest  is  essential  in  the  after-treatment  of  wounds,  to  avoid  tension  on  the 
stitches.  In  large  wounds  this  is  best  secured  by  rest  in  bed  in  a  comfortable 
position.  With  the  present  methods  of  hsemostasis  and  wound-closing  one 
has  no  fear  of  secondary  hemorrhage  and  it  is  unnecessary  to  keep  patients 
for  a  long  time  in  one  position.  The  careful  changing  of  the  patient  in  bed 
will  not  disturb  the  wound  and  will  rest  the  patient,  but  a  restless,  nervous 
patient  may  do  harm  by  causing  tension  of  the  borders  of  the  wound.  Rest  of 
an  extremity  can  be  secured  by  its  elevation,  by  frequent  change  of  position, 
and  by  the  application  of  a  plaster-of-Paris  or  some  other  variety  of  splint. 
Since  John  Hunter  published  his  famous  dictum,  that  the  first  and  great  recjui- 
site  for  the  restoration  of  injured  parts  is  rest,  physicians  and  surgeons  have 
never  ceased  to  be  cognizant  of  its  virtues.  Rest  as  a  therapeutic  agent  has 
been  greatly  abused  in  certain  directions,  and  a  reaction  is  taking  place.  This 
is  specially  true  in  surgery  because  we  have  learned  that  when  a  wound  is  once 
thoroughly  healed  the  sooner  the  patient  uses  the  part  the  sooner  its  function  will 
be  restored.  Surgeons  no  longer  keep  their  patients  in  bed  as  long  as  formerly 
after  operations  and  injuries.     The  greatest  abuse  of  rest  has  been  in  treating 


GENERAL  SURGICAL  TREATMENT.  755 

sprains  and  tuberculous  joints.  The  rest  treatment  of  a  sprained  ankle  continued 
for  a  series  of  weeks  made  it  worse  than  a  fracture.  The  prolonged  rest  of 
healthy  knee  joints  for  patients  suffering  from  tuberculosis  of  the  hip  has  with- 
out doubt  caused  in  many  cases  bad  results.  It  is  the  surgeon's  duty  to  see 
that  his  patient  gets  rest  when  it  is  indicated,  and  to  decide  at  the  earliest 
moment  when  activity  of  body  and  joint  shall  begin. 

Where  there  is  loss  of  integument  and  for  any  reason  skin  grafts  are  not 
applied,  a  good  way  of  dressing  the  raw  surface  is  to  use  strips  of  sterile  rubber 
tissue  over  the  whole  surface,  like  the  shingles  on  a  roof.  This  allows  the  escape 
of  the  discharges  from  the  wound  into  the  dressings  and  prevents  the  dressings 
from  adhering  to  the  wound.  It  is  necessary  to  change  this  kind  of  dressing 
frequently  because  it  soon  becomes  soiled  and  uncomfortable.  A  hand  or  foot, 
or  a  sterile  raw  surface,  can  be  very  satisfactorily  dressed  by  applying  sterile  gauze 
directly  and  leaving  it  mrdisturbed  for  seven  or  eight  days.  The  outer  dressings 
can  then  be  removed  and  the  hand  or  foot  with  the  adherent  gauze  immersed  in 
a  bowl  of  warm  sterile  water  until  the  gauze  loosens.  This  leaves  a  layer  of  clean 
healthy  granulations.  It  is  bad  practice  to  remove  adherent  gauze  from  a 
wound  by  force,  because  it  breaks  down  the  granulations,  hinders  repair,  offers 
a  new  entrance  for  bacteria,  and  causes  the  patient  unnecessary  suffering. 

Suspected  Wounds. — Every  accident  wound  and  every  operation  wound 
where  aseptic  precautions  have  not  been  observed,  is  open  to  suspicion  and 
should  be  treated  as  if  infection  had  taken  place.  The  chances  for  success- 
fully disinfecting  a  clean-cut  wound  are  much  better  than  in  the  case  of  a  lacer- 
ated or  contused  wound,  because  in  the  latter  there  is  more  liability  to  infection. 
A  good  example  of  a  clean-cut  wound  is  an  accidental  cut  across  the  palmar 
surface  of  the  wrist  caused  by  some  sharp-cutting  instrument.  The  hemorrhage, 
which  will  be  severe,  is  the  first  consideration.  It  should  be  temporarily  checked 
by  pressure  upon  the  arteries  above  and  perhaps  below  the  wound  by  fingers  or 
bandage  and  compress.  It  is  seldom  justifiable  to  introduce  an  unsterilized 
instrument  to  stop  hemorrhage.  The  surgeon  should  prepare  himself  and 
his  instruments  and  get  his  dressings  ready.  He  cleanses  the  hand  and  arm 
as  if  preparing  for  an  operation,  and  finally  cleanses  the  wound  with  sterile 
salt  solution  and  a  bit  of  gauze.  The  arteries  are  next  tied  with  catgut,  and 
the  tourniquet  removed.  The  median  and  ulnar  nerves  should  be  examined 
and,  if  severed,  they  should  be  united  by  fine  chromicized  catgut  sutures.  Two 
sutures  should  be  passed  through  the  distal  and  proximal  ends  of  the  nerve 
with  a  round-pointed  needle,  the  ends  approximated  and  the  sutures 
tied.  A  few  stitches  should  be  placed  in  the  connective  tissue  around  the 
nerve  in  such  a  manner  as  to  prevent  undue  tension  upon  the  nerve  sutures.  The 
severed  tendons  should  next  be  isolated  and  carefully  sutm-ed  with  chromicized 
catgut,  great  care  being  exercised  that  >each  end  shall  be  sutured  to  its  fellow. 
It  will  frequently  be  necessary  to  slit  up  the  tendon  sheaths  to  secure  the  proxi- 


756  AMERICAN  PRACTICE  OF  SURGERY. 

mal  ends  on  account  of  muscular  contraction.  When  this  has  been  done  the 
sheaths  should  be  united  by  a  running  stitch  of  fine  unchromicized  catgut. 
When  the  wound  has  been  made  by  a  bright  sharp  instrument  it  can  be  safely 
closed  after  a  careful  cleaning.  The  superficial  fascia  should  be  closed  by  a 
running  stitch  of  fine  catgut,  and  finally  the  integument  should  be  closed  with 
silk  or  silkworm-gut  sutures.  A  dry  dressing  of  sterile  gauze  and  cotton  is 
then  applied,  and  the  hand  held  in  a  flexed  position  by  a  splint  so  as  to  keep 
the  parts  at  rest  in  a  relaxed  state.  If  there  is  no  unusual  temperature  this 
dressing  should  be  left  for  one  week,  when  the  stitches  are  to  be  removed  and 
a  gauze  dressing  and  the  splint  reapplied.  As  time  goes  by,  the  hand  may 
be  gradually  extended  so  that  it  shall  be  straight  by  the  end  of  the  fourth  week, 
which  is  about  the  time  required  for  a  tendon  to  unite.  Should  there  be  some 
elevation  of  temperature  and  local  evidences  of  infection  after  two  or  three 
days,  some  of  the  superficial  stitches  must  be  removed  and  the  wound  treated 
as  an  infected  one.  Chemical  disinfectants  are  not  recommended  in  this  class 
of  wounds  because  an  effort  should  always  be  made  to  secure  primary  union, 
and  they  would  be  more  likely  to  prevent  than  to  secure  this  result. 

A  lacerated  and  contused  wound  is  usually  an  infected  wound  and  should 
be  treated  as  such.  A  compound  comminuted  fracture  of  the  leg  is  a  good 
example  of  this  kind  of  wound.  It  is  presumed  that  the  arterial  and  nerve 
supplies  are  not  injured  to  such  an  extent  as  to  demand  amputation.  The 
hemorrhage,  if  free,  should  be  promptly  controlled  by  forceps  and  catgut  ligature. 
The  sm'geon  should  first  prepare  himself,  then  the  leg,  then  himself  again, 
and  finally  the  wound.  The  leg  should  be  scrubbed,  shaved,  and  prepared  as 
for  an  operation.  All  infectious  agents  like  pieces  of  clothing,  etc.,  and  all 
fragments  of  bone  should  be  removed.  When  there  is  dirt  in  the  wound  the 
latter  should  be  thoroughly  cleansed  with  tincture  of  soap  and  warm  water,  aided 
by  the  fingers  and  a  piece  of  soft  gauze.  Pieces  of  tissue  that  have  evidently 
lost  their  circulation  should  be  cut  away.  After  it  has  been  washed  with  soap  the 
wound  should  be  rinsed  with  warm  sterile  water,  followed  by  a  warm,  weak 
solution  of  bichloride  of  mercury.  It  is  useless  to  introduce  the  bichloride 
solution  into  a  soapy  wound.  The  fragments  of  bone  should  be  adjusted  and, 
when  they  cannot  be  held  in  position  by  splints  and  bandages,  they  should 
be  drilled  and  fastened  together  by  silver  wire  or  strong  chromicized  catgut, 
preferably  the  latter.  No  iodoform  or  other  powders  should  be  put  into  the 
wound.  Folded  strips  of  rubber  tissue  or  of  gauze  rolled  in  rubber  tissue  in 
the  form  of  a  "cigarette"  drain,  are  so  placed  that  they  shall  extend  from  the 
depths  of  the  wound  tlii'ough  the  skin.  They  should  not  be  large  or  numerous. 
Two  will  usually  suffice.  The  wound  should  not  be  plugged  with  iodoform  or 
other  gauze,  as  it  prevents  drainage  and  healing.  The  pliable  rubber  tissue 
is  better  than  rubber  tubes  because  it  drains  as  well  and  does  not  injure  the 
tissues  by  pressure,  as  a  stiff  tube  ma3^     The  wound  when  large  should  be  partly 


GENERAL  SURGICAL  TREATMENT.  757 

closed  by  loosely  tied  stitches  of  silkworm  gut.  It  is  not  necessary  to  leave 
the  wound  wide  open  to  secure  drainage.  The  usual  dry  sterile  dressing  of 
gauze  and  absorbent  cotton  should  be  applied  and  the  leg  supported  by  a  proper 
splint.  The  moist  dressing  should  not  be  applied  at  first  because  it  is  often 
possible  even  in  this  class  of  cases  to  secure  an  aseptic  wound,  and  the  moisture 
would  encourage  bacterial  development.  It  will  be  time  enough  to  apply  a 
moist  dressing  when  suppuration  is  inevitable.  This  dry  dressing  may  be  left 
for  four  days  unless  there  is  a  suggestive  rise  of  temperature  or  the  dressing 
becomes  soiled.  At  that  time,  if  it  is  apparent  that  an  aseptic  wound  has  been 
secured,  the  drainage  material  may  be  removed  and  a  fresh  dry  dressing 
applied.  If,  on  the  other  hand,  the  temperature  rises  or  other  evidences  of  in- 
fection appear,  the  dry  dressings  should  be  exchanged  for  moist  ones  and  the 
wound  treated  as  an  infected  one.  So  long  as  the  wound  remains  aseptic  it 
should  not  be  irrigated  or  disturbed  except  for  the  removal  of  drainage  materials 
and  stitches,  and  the  dressings  should  be  changed  only  when  the  temperature 
rises  or  when  they  cause  discomfort. 

Secondary  suturing  of  wounds  is  employed  in  aseptic  wounds  that  have  been 
drained  and  for  the  approximation  of  granulating  surfaces.  When  drain- 
age is  employed  where  it  is  hoped  that  an  aseptic  wound  may  be  secured,  and 
the  amount  of  drainage  material  used  is  enough  to  cause  gaping  of  the  wound, 
sutures  should  be  introduced  at  the  time  of  the  first  dressing  and  tied  when 
the  drainage  material  is  removed.  When  aseptic  granulating  surfaces  can  be 
brought  together  without  tension  they  will  heal  by  first  intention.  Through-and- 
through  sutures  passing  underneath  the  whole  granulating  surface  should  be 
employed  when  possible.  It  is  useless  to  force  the  edges  of  a  gaping  granulat- 
ing wound  together  with  sutures  under  tension,  because  the  sutures  will  cut 
through  and  do  more  harm  than  good.  Under  these  circumstances  it  is  better 
to  approximate  the  surfaces  with  strips  of  adhesive  plaster,  supplemented  by 
a  comfortably  fitting  bandage. 

Infected  Wounds. — In  preantiseptic  da3^s  most  wounds  were  septic  and 
suppuration  was  so  common  that  it  was  considered  a  necessary  part  of  the 
healing  process,  and  "laudable  pus"  was  spoken  of  as  something  to  be  sought 
for.  At  the  present  time  suppuration  is  known  to  be  a  pathologic  process  due 
to  the  presence  of  certain  forms  of  bacteria  in  the  wound,  and  when  suppuration 
occurs  in  an  operation  wound  the  surgeon  or  some  of  his  helpers  may  be 
responsible  for  it.  In  the  preantiseptic  days  abdominal  operations  were  very 
rarely  performed  because  they  were  so  commonly  fatal,  the  patients  dying  from 
peritonitis.  It  was  not  unusual  in  those  days  for  a  medical  student  to  go  through 
his  whole  medical  course,  even  where  there  were  large  surgical  clinics,  without 
seeing  a  single  abdominal  operation.  At  the  present  day  peritonitis  following 
operation  is  almost  abolished  and  operations  are  often  performed  for  the  relief 
of  that  condition.     When  a  wound  has  been  infected  it  may  finally  heal  by  what 


758  AMERICAN  PRACTICE  OF  SURGERY. 

is  kno-mi  as  secondary  intention.  In  a  suppurating  wound  the  superficial 
layers  of  new  cells  formed  by  the  tissues  for  the  healing  of  the  wound  are  de- 
stroyed by  pus  microbes  and  their  toxins  and  they  finally  help  to  form  pus. 
ANlyen  this  process  is  very  active,  the  healuig  of  the  wotind  is  interfered  with. 
When,  through  Nature's  efforts,  and  with  the  aid  of  the  surgeon,  a  favorable 
change  takes  place,  the  pus  becomes  less  virulent  and  diminishes  in  quantity. 
The  new  cells  become  more  highly  organized,  and  healing  by  secondary  intention 
gradually  takes  place.  The  pathology  of  inflammation  is  partly  based  upon 
theory,  and  jjathologists  do  not  agree  concerning  suppuration,  some  claiming  that 
it  is  purely  pathologic,  while  others  claim  that  it  serves  a  useful  purpose  in  com- 
bating invading  organisms.  The  surgeon  knows  practicalh^,  however,  that 
when  there  are  no  bacteria  in  a  wound  there  will  be  no  suppuration,  no  matter 
what  the  character  of  the  wound  or  where  situated,  and  his  best  efforts  are 
therefore  put  forth  to  prevent  infection  and  consequent  suppuration.  Aside 
from  the  dangers  and  loss  of  time  which  attend  a  suppurating  wound,  healing 
by  second  intention  is  unsatisfactory  because  of  the  large  scar  which  it  leaves. 
Accident  wounds  are  suspicious  wounds,  and  many  of  them  do  not  come  under 
the  surgeon's  care  until  after  suppuration  is  well  established.  The  principles 
connected  with  the  treatment  of  these  wounds  are  the  same  as  those  for  the 
treatment  of  other  wounds,  but  the  details  differ  somewhat.  When  the  evi- 
dences of  infection — heat,  pain,  and  redness  of  surrounding  parts — are  present, 
the  surgeon's  first  efforts  should  be  to  allay  the  inflammation,  the  healing  of 
the  wound  being  then  a  secondary  consideration.  The  discharges  must  be 
allowed  free  exit  to  prevent  their  absorption  and  dissemination  from  causing 
a  general  infection.  If  the  wound  is  a  deep  one  it  must  either  be  drained  by 
tubes  or  strips  of  rubber  tissue  or  be  opened  widely  with  the  knife.  It  must 
not  be  packed  with  gauze,  because  gauze  prevents  drainage.  It  is  a  common 
error  to  pack  a  wound  with  medicated  gauze  under  the  mistaken  idea  that  it 
will  drain  it.  In  treating  infected  wounds  a  rational  use  should  be  made  of 
the  best  antiseptic  and  aseptic  precautions ;  not  that  they  will  necessarily  stop  the 
suppuration,  but  that  they  may  prevent  the  engrafting  of  another  infection  upon 
the  one  already  existing.  It  is  quite  possible,  for  example,  to  inoculate  a  sup- 
purating wound  with  the  streptococcus  of  erysipelas  or  with  the  tetanus  bacillus. 
Our  knowledge  of  the  exact  relations  of  associated  bacteria  is  quite  limited. 
In  suppurating  wounds  the  infection  is  usually  a  mixed  one,  but  there  are  very 
few  instances  known  when  the  various  forms  of  bacteria  are  at  warfare  with 
each  other;  on  the  contrary,  the  tendency  is  for  them  to  unite  their  forces 
against  the  resisting  powers  of  the  tissues.  Persistent  or  repeated  irrigation 
of  a  suppurating  wound  with  strong  chemical  solutions  does  more  harm  than 
good.  It  does  not  stop  the  suppuration  and  it  is  liable  to  injure  the  already 
weakened  embryonic  cells  of  the  granulation  tissue.  Every  experienced  sur- 
geon has  observed  patients  with  suppurating  wounds  which  had  refused  to 


GENERAL  SURGICAL  TREATMENT.  759 

heal  under  chemical  irrigation,  but  which  promptly  improved  after  the  irrigation 
had  been  discontinued.  It  is  not  practicable  to  use  solutions  strong  enough 
or  for  a  period  sufhcientl}^  long  to  act  as  germicides,  without  danger  of  poison- 
ing the  patient.  There  is  a  growing  belief  that  a  claret-colored  solution  of  iodine 
will  accomplish  much  toward  securing  the  desired  result.  Gentle  irrigation 
with  a  warm  normal  salt  solution  meets  every  indication,  since  the  only  benefit 
to  be  derived  from  irrigation  is  a  mechanical  cleansing  of  the  wound.  The 
advantage  of  the  salt  solution  over  the  sterile  water  is  that  it  is  more  grateful 
to  the  tissues.  A  wound  so  situated  and  so  shaped  that  it  can  be  cleansed  by 
gently  touching  it  with  pieces  of  soft  gauze  will  heal  more  promptly  without 
irrigation  of  any  kind. 

The  poultice,  so  popular  with  the  profession  at  one  time  and  which  still 
holds  a  prominent  place  in  domestic  surgery,  has  almost  entirely  given  place 
to  the  moist  gauze  dressing.  The  poultice  is  an  application  soothing  to  an 
inflamed  part  on  account  of  its  warmth  and  moisture,  but  as  usually  made 
it  is  objectionable,  and  consequently  it  may  become  a  source  of  danger. 

Salves  and  ointments,  at  one  time  so  extensively  used,  have  fallen  into  disuse 
because  they  were  found  to  be  surgically  unclean;  however,  they  can  be  made 
in  such  a  manner  as  to  be  a  clean  and  comfortable  dressing.  Some  of  the  heavier 
products  of  petroleum  make  the  best  ointments.  When  properly  sterilized 
and  impregnated  with  sufficient  carbolic  acid  to  prevent  them  from  becoming 
infected,  they  make  a  very  grateful  dressing  for  a  granulating  surface.  They 
can  be  spread  upon  gauze  and  applied  directly  to  the  wound.  A  granulating 
wound,  which  has  become  weak  under  rubber  tissue  or  moist  dressings,  will 
often  improve  rapidly  under  the  above  dressing. 

The  moist  gauze  dressing  has  all  the  advantages  of  a  poultice  without  its 
disadvantages.  There  is  no  clinical  evidence  that  medicated  gauze  commonly 
has  any  advantage  over  simple  sterile  gauze.  Surgeons  who  at  one  time  used 
medicated  gauzes  quite  exclusively  now  find  that  they  can  secure  better  results 
with  the  unmedicated  gauze.  The  medicated  gauzes  are  open  to  the  same 
objections  as  powders  and  chemical  solutions — weak  ones  may  do  no  good, 
and  strong  ones  may  do  harm. 

After  the  wound  has  been  gently  cleansed  it  should  be  covered  with  a  liberal 
layer  of  sterile  gauze  wet  in  sterile  water.  Very  weak  solutions  of  lysol  and 
carbolic  acid  will  give  a  perfume  of  their  own  to  the  dressings  and  are  harmless, 
but  they  have  no  perceptible  therapeutic  value.  An  ample  quantity  of  the 
moistened  gauze  should  be  applied,  and  over  this  should  be  placed  a  layer  of 
rubber  tissue  to  retain  the  moisture.  The  advantages  of  the  moist  over  the 
dry  gauze  in  this  class  of  wounds  are  these:  they  do  not  adhere  to  the  wound 
and  they  absorb  the  discharges  more  quickly.  Over  the  rubber  tissue  a  layer 
of  cotton  should  be  applied,  and  the  whole  held  comfortably  in  place  by  a  band- 
age.    This  dressing  should  be  changed  every  three  or  six  hours  according  to 


760  AMERICAN  PRACTICE  OF  SURGERY. 

the  amount  and  character  of  the  discharges.  Thej^  should  never  be  permitted  to 
become  dry.  A  chill  or  a  rise  of  temperature  indicates  that  the  wound  is  not 
adequately  drained,  that  there  is  systemic  infection,  or  that  there  is  some  other 
focus  or  a  complication,  all  of  which  are  conditions  that  call  for  prompt  atten- 
tion. When  the  suppuration  has  been  reduced  to  a  minimum,  the  moist  dress- 
ings should  be  replaced  by  dry  ones  and  an  effort  made  to  secure  rapid  healing. 
When  we  have  a  granulating  surface  to  deal  with,  it  should  be  covered  by  strips 
of  rubber  tissue,  and  over  the  whole  should  be  placed  dry  sterile  gauze.  When 
the  wound  is  so  situated  or  so  shaped  that  the  granulating  surfaces  can  be 
approximated  without  tension,  secondary  sutures  or  adhesive  plaster  may  be 
used  for  this  purpose,  provided  the  surfaces  can  be  made  sterile.  It  is  only 
in  exceptional  cases,  however,  that  this  is  possible,  but  it  may  be  secured  often 
enough  to  make  the  effort  well  worth  while.  For  example,  if  an  abdominal 
wound  which  presents  clean  granulating  smfaces  and  has  practically  ceased 
suppurating  be  carefully  dried,  then  thoroughly  swabbed  with  ninety-five- 
per-cent  carbolic  acid  followed  by  alcohol,  then  packed  for  forty-eight  hours 
with  gauze  saturated  with  balsam  of  Peru,  and  finally  closed  by  sutm-es  or 
adhesive  plaster,  it  will  sometimes  heal  promptly,  and  when  it  does  not  heal 
at  once  the  healing  is  at  least  hastened  by  this  treatment.  When,  as  sometimes 
happens,  the  rubber  strips  are  uncomfortable,  a  very  good  and  comfortable 
di-essing  can  be  made  of  gauze  saturated  in  a  mixture  of  six-per-cent  balsam 
of  Peru  in  sterilized  castor  oil. 

A  suppurating  compound  comminuted  fractiue  of  the  leg  may  be  taken  as 
an  example  of  this  variety  of  wound.  This  is  a  particularly  dangerous  variety 
of  wound  because  the  soft  parts  are  usually  badly  injured,  and  because  there 
is  danger  of  the  burrowing  of  pus  between  the  muscles.  In  addition,  the  medulla 
of  the  bone  is  exposed,  and  consequently  there  is  imminent  danger  that  a  sup- 
purating osteomyelitis  maj^  develop.  The  surgeon's  hands,  instruments,  and 
dressings  should  first  be  prepared.  The  leg  should  then  be  shaved  and  scrubbed 
with  soap,  warm  water,  and  brush.  Finally,  the  wound  should  be  thoroughly 
irrigated  with  a  warm  normal  salt  solution.  If  one  who  has  been  accustomed 
to  use  a  strong  bichloride  solution  in  these  cases  will  substitute  a  normal  salt 
solution  he  will  meet  with  an  agreeable  surprise.  If  the  surgeon  believes  that 
a  chemical  solution  must  be  employed,  the  iodine  solution  is  probably  the 
safest  and  most  efficient.  All  parts  of  the  wound  must  be  reached  and  gentle 
pressure  should  be  made  along  the  leg  from  both  distal  and  proximal  ends 
toward  the  wound  to  ascertain  whether  there  is  burrowing.  When  the  original 
skin  wound  is  not  large  enough  to  admit  of  a,  free  cleansing  and  ample  drainage 
it  should  be  enlarged,  and  when  the  wound  does  not  permit  free  access  counter- 
openings  should  be  made.  When  burrowing  is  found,  the  pus  pocket  must 
be  slit  up  or  drained  from  the  bottom.  The  wound  should  be  gently  but  thor- 
oughly explored  with  the  finger,  and  if  any  loose  spicule  of  bone  or  foreign 


GENERAL  SURGICAL  TREATMENT.  761 

matters  are  found  they  should  be  removed.  The  fragments  should  be  adjusted 
and  held  in  place  by  extension  made  by  an  assistant  pulling  on  the  foot  until 
the  dressings  and  splint  are  applied.  Rubber  tubes  or  folded  strips  of  rubber 
tissue,  preferably  the  latter,  should  be  passed  to  the  depths  of  the  wound  and 
allowed  to  project  from  the  wound  for  drainage.  A  large  dressing  of  sterile 
gauze  wrung  out  of  warm  sterile  water  should  be  applied.  Over  this  a  large 
sheet  of  rubber  tissue  and  a  layer  of  absorbent  cotton  should  be  applied  and 
held  in  place  by  a  snug-fitting  roller  bandage.  A  comfortable  splint  should  then 
be  applied  with  some  mechanical  arrangement  by  which  free  access  can  be 
gained  to  the  woimd  for  a  change  of  dressings  without  disturbing  the  fragments. 
These  dressings  should  be  changed  often  enough  to  keep  the  wound  clean  and 
the  dressings  moist.  A  chill  or  rise  of  temperature  always  demands  examina- 
tion of  the  wound  and  perhaps  a  change  of  dressings.  The  latter  should  be 
continued  until  such  time  as  the  wound  has  so  improved  as  to  permit  the  appli- 
cation of  strips  of  rubber  tissue  and  a  dry  gauze  dressing. 

Drainage. — Drainage  in  some  form  has  been  employed  since  the  days  of 
Hippocrates.  Old-time  surgeons  drained  because  they  knew  pus  would  form, 
later  surgeons  drained  to  prevent  the  formation  of  pus,  and  now  we  drain  only 
when  we  have  a  suspected  or  infected  wound  or  where  there  is  unavoidable 
dead  space.  During  the  development  of  antiseptic  and  aseptic  surgery  drainage 
was  a  very  common  topic  for  discussion.  Hippocrates  first  used  drainage  tubes 
for  the  treatment  of  empyema.  Celsus  and  Galen  used  them  for  drainage  in 
ascites.  Ambroise  Pare  used  gold  and  silver  tubes.  Heister  first  employed 
capillary  drainage  in  the  eighteenth  century.  At  the  beginning  of  abdominal 
surgery  drainage  was  very  extensively  used,  and  for  many  years  it  occupied  a 
prominent  place.  Surgeons  then  believed  that  peritonitis  was  only  an  excep- 
tional cause  of  death,  but  that  death  was  due  to  the  absorption  of  what  Keith 
called  "that  red  serum,  the  enemy  of  the  ovariotomist."  Peaslee  and  Keith, 
in  1864,  were  the  first  to  recommend  peritoneal  drainage  tlirough  the  vagina. 
About  this  time  drainage  through  the  rectum  was  tried;  but  from  our  present 
viewpoint  we  can  readily  understand  why  this  proved  fallacious.  The  soft- 
rubber  tubes  now  in  use  were  introduced  by  Chassaignac  in  1859.  Koeberle 
introduced  perforated  bulbous-ended  glass  tubes  for  peritoneal  drainage  in 
1867,  and  soon  after  this  Keith  and  Wells  introduced  straight  glass  tubes. 
These  were  all  very  popular  for  a  time,  but  gradually  fell  into  disuse  because 
they  soon  became  plugged  and  failed  to  drain.  At  that  time  drainage  was 
considered  a  necessary  part  of  the  toilet  of  every  wound,  and  more  especially 
of  an  abdominal  wound.  Marion  Sims  was  originally  an  earnest  advocate  of 
peritoneal  drainage,  but  he  was  one  of  the  first  to  recognize  the  fact  that  the 
opening  of  an  abdomen  does  not  necessarily  indicate  the  need  for  drainage. 
With  the  development  of  antiseptic  surgery  surgeons  learned  that  it  is  not  the 
serum  that  endangers  the  patient,  but  the  presence  of  bacteria.    They  also 


762  Ai\IERICAX  PRACTICE  OF  SURGERY. 

learned  that  drainage  is  a  soui'ce  of  danger  because  it  serves  as  an  entrance- 
way  for  bacteria,  and  therefore  peritoneal  drainage  by  tubes  soon  began  to 
fall  into  disrepute.  It  was  still  belie^-ed  at  this  time  that  peritoneal  drainage 
was  very  often  necessary,  but  surgeons  began  to  realize  that  the  tubes  were 
not  only  dangerous,  but  that  they  were  inefficient.  Many  varieties  of  tubes 
from  manjf  materials  were  tried,  onlj'^  to  be  discarded  because  of  their  dangers 
and  inefficiency.  Capillary  drainage  with  gauze  was  next  tried,  but  it  was  soon 
found  that  it  will  not  chain  pus  and  that  it  drains  serum  from  the  peritoueimi 
for  onh^  a  few  hours,  when  its  meshes  become  plugged  and  its  capillarity  is  de- 
stroyed, and  that  ftirthermore  it  becomes  adherent  to  the  peritoneum.  The 
gauze  was  then  ^Tapped  with  rubber  tissue  to  prevent  adliesion,  and  this  va- 
riety' of  di'ainage  is  much  in  vogue  to-da3^  Prophylactic  abdominal  ch'ainage 
was  at  one  time  given  an  extensive  trial,  but  was  found  to  be  inefficient  and 
dangerous.  We  have  been  guilt}'  of  many  errors  in  the  matter  of  drainage, 
and  our  sins  of  commission  have  doubtless  greatly  outnumbered  those  of  omis- 
sion, but  we  were  obliged  to  go  through  this  experience  in  order  to  learn  what 
is  necessary  and  what  is  uimecessar}'',  and  what  makes  for  good  and  what  for 
ill.  .\11  drainage  openings  become  more  or  less  infected,  although  all  do  not 
suppurate.  The  great  trouble  ■nith  peritoneal  drainage,  aside  from  its  dangers, 
is  that  it  does  not  ch'ain.  Experience  and  experiment  have  demonstrated 
that  it  is  a  ph5'siological  and  mechanical  impossibility  to  drain  the  peritoneal 
ca\ity  for  more  than  a  few  hours.  Drainage  from  tubes  ceases  in  about  twelve 
hom's  and  from  gauze  in  twentj^-four  hom-s,  because  thej'  are  invariably  walled 
off  from  the  general  peritoneal  cavity  in  this  time.  There  may  be  some  flow 
of  serum  after  this  time,  but  it  comes  onlj^  from  the  drainage  track  and  is  caused 
by  the  presence  of  the  drain. 

The  question  of  drainage  is  verj-  important,  and,  unfortunatel}-,  it  is  im- 
possible to  lay  down  exact  rules  as  to  when  we  shall  or  shall  not  drain,  because 
conditions  vary  with  the  patient,  the  envhomnent,  and  the  operator.  From 
our  present  viewpoint  much  of  the  drainage  done  a  few  years  ago  was  unneces- 
sarj'  and  harmful,  but  it  is  quite  probable  that  when  sm'geons  emplo3-ed  it  so 
extensivel}'  they  needed  it  more  than  we  do.  It  is  very  certain  that  in  pre- 
antiseptic  daj-s  it  was  very  much  needed.  If  at  the  present  time  one  sm-geon 
uses  drainage  where  others  do  not  find  it  necessarj',  it  is  quite  possible  that  he 
needs  it.  The  occasional  operator  undoubtedl}'  needs  it  much  more  frequently 
than  the  regular  surgeon,  and  it  is  certainly  rec^uu-ed  in  a  very  much  larger 
percentage  of  accident  than  of  operation  wounds.  Prophylactic  drainage,  or 
drainage  to  prevent  the  formation  of  pus,  is  no  longer  used. 

The  materials  most  frequently  employed  now  are  the  soft-rubber  tube  of 
various  sizes,  rubber  tissue,  and  gauze.  The  glass  drainage  tube,  although 
in  many  respects  excellent,  is  not  so  extensive!}'  used  as  it  was  at  one  time, 
because   its  length  cannot  be  regulated  as  easily  as  that  of  the  rubber  tube. 


GENERAL  SURGICAL  TREATMENT.  763 

The  tube  should  be  employed  where  large  quantities  of  pus  and  large  cavities 
or  cysts  are  to  be  drained,  as  for  empyema  and  for  certain  conditions  of  the 
lu'inary  and  the  gall  bladder.  Folded  rubber  tissue  is  superior  to  the  tube 
when  it  is  applicable,  because  it  is  more  flexible,  is  less  likely  to  do  harm  from 
pressure,  and  does  not  cause  gaping  of  the  wound.  This  material  is  really 
very  efficient,  because  it  keeps  the  wound  open  enough  without  overdoing  it, 
and  the  discharges  escape  along  the  side  of  the  drain.  For  small  accident 
wounds,  and  for  larger  ones  where  suppuration  is  not  abeady  established,  the 
rubber  strips  are  the  best  material.  For  capillary  drainage,  gauze  is  now  the 
favorite  material,  although  horsehair  and  silkworm  gut  are  frequentlj'  used. 
Catgut  and  other  absorbable  materials  have  been  disappointing  as  drainage 
materials  on  account  of  their  tendency  to  become  infected.  Gauze  is  very 
commonly  surrounded  by  rubber  tissue  to  prevent  it  from  adhering  to  the 
tissues;  this  is  especially  true  in  the  peritoneal  cavity.  This  combination 
of  the  two  varieties  of  material  affords  both  capillar}-  and  tubular  drainage. 
The  gauze  drains  the  serum  by  capillary  attraction,  while  pus  and  other  heavy 
discharges  escape  along  the  side  of  the  rubber  tissue.  This  so-called  "cigarette" 
drain  should  be  made  by  laying  a  piece  of  sterile  rubber  tissue  of  the  required 
size  upon  a  table  covered  with  a  sterile  towel,  and  upon  this  about  four  thicknesses 
of  sterile  gauze  a  little  smaller  than  the  sheet  of  rubber  should  be  spread;  then 
all  are  rolled  rather  loosely  into  a  "cigarette."  It  should  be  made  by  the  oper- 
ating-room nurse  when  she  is  prepared  as  for  an  operation.  This  makes  the  best 
drain  of  the  kind,  as  it  is  made  of  alternating  layers  of  gauze  and  rubber  tissue 
with  the  rubber  outside,  and  affords  drainage  of  both  kinds.  It  does  not  adhere 
and  can  be  removed  at  any  time  without  causing  pain  or  injuring  the  granu- 
lations. Capillary  drainage  with  gauze  is  apt  to  be  injudiciously  employed. 
Medicated  gauze  should  not  be  used  as  a  drain  because  it  has  no  advantage 
over  plain  gauze,  and  the  drug  may  do  harm.  Sterile  gauze,  like  every  other 
drainage  material,  is  a  foreign  body  in  the  wound;  therefore  the  minimum 
amount  that  will  meet  the  requirements  should  be  used,  and  it  should  beremo^'ed 
at  the  earliest  possible  moment.  When  gauze  is  used  as  a  packing  to  control 
hemorrhage  it  may  be  necessary  to  use  a  considerable  quantity  and  to  leave 
it  for  from  four  to  six  days  or  until  it  loosens,  but  this  is  not  drainage.  The  ob- 
jections to  gauze  as  a  drainage  material  are  these:  it  drains  only  serum  and  that 
only  for  a  few  hours:  and  when  it  is  removed  the  act  of  removal  may  break 
down  the  granulations,  causing  pain  and  hemorrhage  and  furnishing  a  new 
entrance-way  for  bacteria.  This  is  a  particularly  dangerous  procedure  in  the 
peritoneum.  Many  lives  have  been  imperilled  by  packing  large  quantities  of 
gauze  in  the  abdomen,  and  incautiously  removing  it  on  the  third  or  fourth  day. 
In  superficial  wounds  the  objections  are  not  so  potent,  but  the  advantages  are 
just  as  few.  Surgeons  have  differed  in  regard  to  the  use  of  gauze  in  the  abdomen. 
When  they  have  an  abscess  to  open  they  carefully  wall  off  the  healthy  viscera 


764  AMERICAN   PRACTICE   OF   SURGERY. 

with  gauze  before  opening  it  because  they  know  from  experience  that  the  pus 
will  not  go  through  it;  then,  after  opening  the  abscess,  they  are  apt  to  pack 
the  abscess  cavity  with  gauze,  expecting  the  pus  to  drain  out  through  it. 

That  drainage  is  often  necessary  all  agree,  but  that  it  may  be  an  evil  none 
can  deny.  Many  objections  can  be  made  to  a  drain,  but  the  principal  ones  are: 
that  it  is  an  irritating  foreign  body;  that  it  makes  an  entrance- way  for  bacteria; 
that  it  necessitates  frequent  dressings;  that  its  removal  may  injure  the  granu- 
lations; and  that  it  keeps  the  wound  open,  delaying  the  healing  process.  In 
the  abdomen  the  presence  of  a  foreign  body  interferes  with  the  natural  resist- 
ance of  the  peritoneum,  and  it  sometimes  predisposes  to  hernia,  fistula,  and 
intestinal  obstruction.  Indications  for  drainage  can  often  be  met  in  some  other 
way.  Strict  asepsis  renders  drainage  unnecessary  in  most  cases.  A  peritoneum 
that  has  been  carefullj'  protected  from  injury  during  an  operation  will  drain 
itself  much  better  than  one  that  is  interfered  with  by  the  presence  of  foreign 
bodies  in  the  shape  of  tubes  and  gauze.  There  are  usually  better  ways  of  con- 
trolling hemorrhage  than  that  of  filling  the  wound  with  gauze. 

Drainage  is  indicated  in  the  presence  of  infection  or  where  the  chances  are 
decidedly  in  favor  of  infection,  and  in  the  presence  of  much  blood  or  cyst  con- 
tents. As  a  rule,  when  the  urinary  bladder  and  the  gall  bladder  are  opened, 
drainage  is  indicated  because  they  are  usually  infected  before  they  are  opened, 
and  it  is  often  necessary  to  make  temporary  provision  for  the  escape  of  the 
contents.  In  large  amputation  wounds  and  after  breast  operations  where 
the  wound  is  closed,  it  is  better  to  drain  temporarily  even  when  the  wound  is 
aseptic,  because  there  is  a  large  raw  surface  which  in  spite  of  the  most  careful 
hsemostasis  will  ooze,  and  serum  will  accumulate  to  fill  the  dead  spaces — results 
which  are  unavoidable.  When  the  lymphatics  in  the  axilla,  neck,  or  any  similar 
regions  are  removed  or  destroyed  by  the  operation,  artificial  drainage  is  very 
necessary  for  a  time.  These  wounds  will  heal  superficially  without  drainage, 
but  the  accumulation  of  serum  and  blood  within  will  delay  the  healing  of  the 
deeper  parts  very  much  and  maj^  lead  to  secondary  infection.  An  amputation 
stump  should  have  two  rubber  tubes,  of  medium  size,  introduced  one  at  each 
angle.  They  should  not  protrude  from  the  wound  so  far  that  they  may  be 
bent  over  and  obstructed  by  the  dressings,  which  should  be  of  dry  sterile  gauze 
and  absorbent  cotton  loosely  applied.  A  stout  silk  thread  should  be  fastened 
to  each  tube  and  left  protruding  beyond  the  dressings,  so  that  the  tubes  can 
be  withdrawn  without  disturbing  the  latter;  for  every  change  gives  the  patient 
pain  and  may  lead  to  secondary  infection.  They  should  be  removed  in  forty- 
eight  hours.  Breast  wounds  should  be  drained  in  the  same  manner,  save  that 
it  is  usually  better  to  make  a  stab  wound  through  the  integument  at  the  most 
dependent  part  just  large  enough  to  admit  a  tube. 

Drainage  materials  should  be  removed  as  soon  as  the  discharges  cease,  for 
by  this  time  they  will  have  performed  their  fimction  and  wlW  thenceforth  only 


GENERAL  SURGICAL  TREATMENT.  765 

act  as  foreign  bodies.  Where  the  surgeon  hopes  to  be  able  to  discontinue  the 
drainage  in  a  day  or  two,  gauze  should  not  be  .used  unless  it  is  surrounded  by 
rubber  tissue,  for  otherwise  its  removal  may  be  dangerous  and  will  surely  be 
painful. 

Abdominal  dramage  always  causes  peritoneal  adhesions,  but  they  may  dis- 
appear after  a  time. 

When  a  wound  has  been  closed  without  provision  being  made  for  drainage, 
and  a  decided  rise  of  temperature  follows,  the  question  of  secondary  drainage 
naturally  arises.  A  temperature  of  102°  or  103°  F.  quite  frequently  occurs 
within  twenty-four  hours,  but  this  is  usually  an  aseptic  temperature  clue  to 
absorption  of  blood,  and  has  no  special  significance.  It  often  occurs  with  a 
simple  fracture  or  with  contusions  where  there  is  no  question  of  infection.  A 
temperature  appearing  on  the  second  or  third  day  and  gradually  rising  com- 
monly means  wound  infection,  and  in  any  event  the  wound  should  then  be 
carefully  examined.  The  peritoneum  is  the  most  tolerant  and  most  capable 
of  self-drainage  of  all  the  tissues;  but  when  once  this  tolerance  has  been  arrested 
and  cannot  be  resumed,  the  patient  dies.  Secondary  drainage  of  the  peritoneum 
in  such  cases  is  practically  useless. 

Surgical  Uses  of  Heat  and  Cold. 

Heat  and  cold  have  been  used  as  therapeutic  agents  in  surgery  from  time 
immemorial.  Their  use  has  been  largelj^  empirical,  based  upon  the  fact  that 
they  relieve  pain.  ]\Iost  of  the  statements  concerning  their  effect  are  still 
empirical  and  difficult  to  prove.  They  are  used  rather  indiscriminately  for 
like  conditions,  heat  being  the  favorite  in  winter  and  cold  in  summer,  with 
seemingly  like  results.  They  have  been  favorites  with  the  profession  as  well 
as  with  the  laity  in  the  treatment  of  inflammation  in  its  various  forms,  but 
suice  we  have  learned  that,  surgically  speaking,  inflanmration  means  the  presence 
and  activity  of  bacteria,  our  faith  has  been  somewhat  shaken,  because  any  degree 
of  heat  or  cold  which  will  not  destroy  the  tissues  can  have  very  little  effect  upon 
them.  The  mere  presence  of  bacteria,  however,  is  not  all  there  is  of  inflamma- 
tion. They  must  be  active,  and  for  their  activity  certain  conditions  of  tem- 
perature and  blood  supply  must  obtain.  It  is  these  conditions  which  we  hope 
to  influence  favorably  by  the  application  of  heat  and  cold.  Since  we  cannot 
hope  to  destroy  the  bacteria  by  these  applications,  our  efforts  must  be  to  assist 
Nature  in  her  warfare  against  them. 

Clinical  evidence  concerning  the  effects  of  heat  and  cold  is  still  conflicting 
and  unreliable  because  observers  have  failed  to  give  Nature  due  credit  for  what 
she  will  do  without  their  aid.  The  more  we  learn  concerning  the  conflict  between 
bacteria  and  the  living  tissues  the  greater  our  respect  for  Nature's  work  and 
the  more  we  realize  that  the  most  we  can  do  is  to  be  her  faithful  assistants. 
When  inflammation  is  superficial  it  is  rational  to  believe  that  we  can  render 


766  AMERICAN  PRACTICE  OF  SURGERY. 

some  assistance  by  the  judicious  use  of  heat  and  cold,  but  when  it  is  deep-seated 
it  is  difficult  to  understand  how  we  can  accomplish  anything  by  their  application. 
Many  theories  have  been  advanced  concerning  this  matter,  but  none  are  proven. 
Writers  will  cite  a  long  series  of  cases  of  appendicitis  in  which  they  have  applied 
cold  or  heat  to  the  abdomen  with  good  results,  and  others  will  cite  a  like  series 
in  which  they  have  kept  their  patients  quiet  in  bed  without  applications  of  any 
kind  and  with  equallj'  good  results.  In  the  light  of  this  evidence  is  it  not  ra- 
tional to  conclude  that,  aside  from  the  relief  from  pain  following  the  application 
of  heat  or  cold,  the  improvement  noted  was  due  to  Nature's  efforts  aided  by  rest? 

In  these  few  remarks  on  the  surgical  uses  of  heat  and  cold  the  "WTiter  does 
not  wish  to  assume  the  role  of  an  iconoclast,  but  he  has  not  cared  to  voice  theo- 
ries which  will  not  bear  the  test  of  intelligent  clinical  observation. 

The  influence  which  local  applications  can  have  upon  the  body  temperature 
cannot  be  great  and  cannot  extend  to  any  depth,  but  they  do  add  materially 
to  the  patient's  comfort  and  are  seemingly  helpful  when  judiciously  handled. 
It  is  probable  that  we  can  accomplish  the  most  good  through  these  agents 
by  controlling  the  circulation  of  the  inflamed  part.  The  hyperemia  which 
follows  an  infection  is  evidence  that  Nature  is  rallying  her  forces  for  the  combat 
with  the  invading  enemy,  but  when  stasis  occurs,  the  enemy  has  the  advantage. 
If  by  the  application  of  heat  and  cold  we  can  facilitate  the  flow  of  blood- through 
the  part  and  prevent  stasis  we  are  certainly  assisting  Nature's  efforts.  These 
agents  influence  the  circulation  by  their  direct  effect  upon  the  superficial  ves- 
sels and  by  stimulating  the  vasomotor  nerves.  That  both  heat  and  cold  con- 
tract the  small  blood-vessels  is  demonstrated  by  their  action  in  controlling 
capillary  hemorrhage.  The  selection  in  each  case  must  be  left  to  the  judg- 
ment of  the  attendant.  When  there  is  no  definite  indication  for  a  choice  it 
may  safely  be  left  to  the  caprice  of  the  patient.  In  a  few  instances,  however, 
a  proper  selection  is  very  important.  For  example,  when  a  hand  or  foot  is 
so  badly  crushed  that  it  is  a  question  whether  it  can  be  saved  or  not,  it  would 
be  a  great  mistake  to  apply  ice,  on  account  of  its  tendency  to  lower  the  vitality 
of  the  tissues.  It  would  be  a  grave  error  to  apply  cold  to  an  ulcerated  cornea 
the  vitality  of  which  is  low.  Cold  is  the  favorite  in  the  early  stages  of  inflam- 
mation when  it  is  hoped  that  suppuration  may  be  averted,  but  in  the  later  stages,, 
when  suppuration  is  deemed  inevitable,  heat  should  take  precedence. 

Heat  may  be  applied  either  moist  or  dry.  When  the  skin  is  unbroken  the 
choice  may  be  made  a  matter  of  convenience,  but,  in  the  presence  of  a  wound,, 
no  application  should  be  made  which  is  not  in  strict  accord  with  the  principles 
of  aseptic  and  antiseptic  surgery.  Moist  heat  in  the  form  of  a  poultice  is  not 
specially  objectionable  when  the  skin  is  whole,  save  that  there  are  many  more 
elegant  methods,  but  when  the  skin  is  broken  moist  heat  is  highly  objectionable, 
because  in  its  usual  form  of  a  poultice  it  is  crowded  with  bacteria  and  intro- 
duces foreign  matter  into  the  wound.     Moist  heat  can  be  best  applied  by  means 


GENERAL  SURGICAL  TREATMENT.  767 

of  sterile  gauze  wrung  out  of  hot  water  and  covered  by  rubber  tissue.  The 
ckessings  must  be  changed  so  frequently  that  they  shall  not  become  cold  and 
dry,  for  alternating  heat  and  cold  are  decidedly  objectionable. 

Dry  heat  is  often  just  as  efficient  as  moist  and  can  be  more  conveniently 
applied  by  means  of  a  rubber  bag  or  coil.  Dry  heat  has  been  extensively  em- 
ployed in  the  treatment  of  inflamed  joints.  The  joint  is  surrounded  by  a  metal- 
lic jacket,  and  the  air  within  is  gradually  heated  to  the  limit  of  endurance.  This 
"baking"  process  is  a  very  efficient  means  of  relieving  pain,  but  its  curative 
effect  has  not  been  sufficiently  demonstrated  to  gain  for  it  an  established  place 
in  treatment. 

Extreme  heat  in  the  form  of  the  actual  cautery  has  an  important,  although 
limited,  place  in  sm-gical  treatment.  It  was  formerly  much  employed  as  a 
means  of  controlling  hemorrhage,  but  at  the  present  time  it  is  rarely  used 
for  that  purpose.  The  use  of  the  cautery  is  practically  limited  now  to  the 
treatment  of  hemorrhoids.  The  Paquelin  cautery  and  the  soldering  irons  are 
still  used,  but  the  electric  cautery  is  the  most  convenient  form  of  instrument. 
Modern  operating-rooms  are  being  provided  with  plugs  so  that  the  electric 
lighting  current  can  be  utilized  for  this  pm-pose. 

Cold  is  usually  applied  dry  by  means  of  an  ice  bag.  Moist  cold  has  no 
advantage  over  dry  and  is  not  nearly  so  convenient  to  apply. 


PART   V. 

GENERAL  SURGICAL  PROGNOSIS, 


GENERAL  PROGNOSIS  IN  SURGICAL  DISEASES 
AND   CONDITIONS. 

By  LEONARD  WOOLSEY  BACON,  JR.,  M.D.,  New  Haven,  Conn. 


It  is  the  business  of  individual  prognosis  to  estimate  the  future  course  of  any 
disease  present  in  the  individual  patient,  to  answer  the  questions :  Will  this  man 
survive  this  illness,  this  accident?  If  he  survives,  will  his  recovery  be  complete 
and  permanent,  will  he  go  forth  whole  and  sound,  or  will  he  always  bear  with 
him  some  disabilities  resulting  from  his  present  condition  of  disease  or  injury, 
or  some  tendency  to  relapse?  If  he  carmot  recover,  how  long  may  he  expect  to 
live,  or  with  what  permanent  disabilities  will  he  be  handicapped? 

Passing  beyond  the  consideration  of  the  prognosis  in  the  case  of  the  indi- 
vidual patient,  special  prognosis  considers  the  outlook  of  all  those  individuals  as 
a  group  who  are  suffering  from  a  particular  ailment,  and  thus  takes  in,  from  the 
point  of  view  of  the  several  species  of  disease,  the  whole  realm  of  medical  and 
surgical  nosology.  That  is  to  say,  individual  prognosis  considers  the  outlook  for 
A.,  B.,  and  C,  suffering,  let  us  say,  with  appendicitis;  while,  passing  from  the 
individual  to  the  group,  special  prognosis  considers  the  wider  subject  of  the  out- 
come of  appendicitis  in  its  different  forms  and  stages,  and  the  results  that  may 
be  expected  imder  different  forms  of  treatment,  expectant  or  operative.  In  this 
way  it  is  the  fimction  of  special  prognosis  to  consider  all  the  units  of  the  noso- 
logical schedule,  and  to  determine  and  weigh  the  prognostic  factors  in  cancer, 
erysipelas,  aneurism,  hernia,  septicaemia,  mechanical  trauma,  etc. 

But,  above  and  beyond  all  this,  aside  from  the  outlook  for  the  particular  pa- 
tient, and  aside  from  the  several  species  of  medical  or  surgical  disease  under 
consideration,  are  the  general  and  fundamental  matters  of  constitution  and  the 
powers  of  resistance. 

Individual  prognosis,  the  ultimate  object  of  all  prognostic  study,  depends,  in 
the  final  analysis,  upon  the  relation  between  the  natural  tendency  of  the  specific 
disease  with  which  the  patient  may  be  affected  (the  special  prognosis)  on  the 
one  hand,  and  the  general  powers  of  resistance  of  the  patient  on  the  other  hand. 
These  matters  of  constitution  and  the  powers  of  resistance  are  the  elements  of 
"general  prognosis,"  they  appear  as  factors  of  prime  importance  in  each  and 
every  case,  and  they  are  to  be  the  theme  of  our  study  in  considering 

771 


772  AilERICAN  PRACTICE  OF  SURGERY. 

GENERAL  PROGNOSIS  IN  SURGICAL  DISEASES  AND  CONDITIONS. 

It  will  be  well  for  iis,  then,  at  the  outset  to  indicate  just  what  are  these  wide- 
reaching  elementary  conditions  which  affect  the  prognosis  in  all  surgical  dis- 
eases and  in  aU  surgical  conditions,  and  then  to  proceed  to  examine  them  in 
more  detail  with  regard  to  their  bearing  upon  special  and  upon  individual 
prognosis. 

I.  Age. — Tire  most  obvious  of  these  general  considerations  is  age.  Infancy, 
childhood,  adolescence,  maturity,  senility — all  present  factors  whose  prognostic 
import  ranges  throughout  the  whole  field  of  medicine  and  surgery. 

II.  Sex. — A  second  matter  is  sex,  though  the  influence  of  sex  is  more  obvious 
upon  the  incidence  of  disease  than  upon  its  prognosis. 

III.  Constitution. — Many  factors  go  to  the  making  up  of  the  constitution  of 
the  individual,  and  our  study  of  this  matter  must  be  sufficiently  broad  to  include 
that  upon  which  oiu-  fathers  laid  great  stress  under  the  caption  of  temperament, 
and  to  include  likewise  a  consideration  of  diathesis,  heredity,  and  race. 

IV.  Integrity  of  Organs  and  Functions. — Integrity  of  organs  and  functions 
and  the  existence  of  concomitant  disease  will  evidently  demand  a  large  share  of 
our  study,  as  including  those  factors  influencing  perhaps  most  closely  the  indi- 
vidual prognosis. 

V.  Environment. — Lastlj',  the  environment  of  the  patient  will  claim  our  at- 
tention, including  under  this  term  his  occupation,  his  food,  the  climatic  condi- 
tions imder  which  he  lives,  his  ability  to  create  about  himself  hygienic  condi- 
tions, and  his  disposition,  through  habit  or  training,  to  observe  the  laws  of 
hj'gienic  living. 

Under  these  five  heads — age,  sex,  constitution,  integritj'  of  organs  and  func- 
tions, and  enviroimient — we  shall  pursue  the  study  of  our  theme. 

I.  Age. 

(a)  Infancy. — It  is  natirrally  in  the  extremes  of  life  that  we  look  for  the  in- 
fluence of  age  upon  surgical  prognosis  to  be  most  pronounced.  As  indicated  by 
Karewski,*  a  very  energetic  cell  activity  is  characteristic  of  infancy  and  child- 
hood. From  this  fact  there  result,  however,  two  apparently  contrary  peculiar- 
ities, at  once  an  enhanced  and  a  diminished  power  of  resisting  noxious  causes. 

The  intensity  of  metabolic  processes  in  childhood  occasions  particularly 
favorable  conditions  for  maintaining  the  conflict  with  micro-organisms  and  for 
the  repair  of  trauma.  We  observe,  indeed,  that  suppurative  affections  are  rela- 
tively rare  in  children,  and  that  solutions  of  continuity  show  a  particularly 
favorable  tendency  to  heal.  In  spite  of  the  great  frequency  of  abrasions  and 
skin  wounds,  which  are  exposed  to  treatment  quite  opposed  to  the  rules  of  mod- 
*  Karewski:  "Die  Chirurgischen  Krankenheiten  des  Kindesalters,"  Stuttgart,  1894. 


GENERAL  SURGICAL  PROGNOSIS.  773 

ern  surgery,  the  surgeon  sees  far  less  frequently  in  the  infant  than  in  the  adult 
progressive  phlegmon  or  general  sepsis  arising  from  these  sources.  Even  chronic 
suppurative  processes,  such  as  after  puberty  would  be  followed  by  rapid  ex- 
haustion, are  astonishingly  well  borne  and  heal  in  a  surprising  manner.  Certain 
chronic  infectious  diseases,  such  as  tuberculosis  and  syphilis,  seem  to  appear,  as 
it  were,  in  an  attenuated  form  in  children,  and  to  proper  therapy  they  yield  much 
better  results  than  in  later  life. 

This  same  condition  of  enhanced  metabolic  activity  results,  on  the  other 
hand,  to  the  disadvantage  of  the  infantile  organism.  Inasmuch  as  the  main- 
tenance of  this  heightened  activity  is  particularly  dependent  upon  favorable  and 
abundant  local  and  general  nutrition,  it  follows  that  all  influences  which  acutely 
and  considerably  reduce  this  abundant  nutrition  are  calculated  to  compromise 
the  health  or  even  the  life  of  the  child — a  fact  that  applies  to  individual  portions 
as  well  as  to  the  whole  body  of  the  child.  Impairment  of  blood  supply  and  dis- 
turbances of  innervation  are  the  occasion  of  marked  trophic  disturbances,  the 
former  even  occasioning  the  prompt  supervention  of  necrosis,  where  in  adults 
the  same  parts  would  have  maintained  their  vitality.  Indeed,  a  permanent  de- 
pression of  the  general  nutrition  brings  about  a  disposition  to  succmnb  to  just 
those  dangers  against  which  the  infantile  organism  is  otherwise  so  particularly 
well  fortified.  Thus  we  understand  how  it  is  that  even  slight  hemorrhage  in 
nursing  children  may  induce  either  sudden  death  or  profound  cachexia,  that 
chilling  of  the  body  during  operation  or  prolonged  narcosis  may  be  followed  by 
fatal  results,  poisonous  antiseptics  bring  about  grave  conditions,  pyogenic  in- 
fections assume  a  virulent  and  dangerous  type.  Conditions  of  malnutrition  in 
children  give  a  great  impetus  to  the  spread  of  micro-organisms,  manifest,  for 
instance,  in  multiple  abscesses  and  miliary  tuberculosis;  while  the  very  same 
cause  occasions  that  characteristic  trophic  disease  of  childhood,  rickets,  which 
has  its  seat  at  the  focus  of  the  most  energetic  developmental  activity. 

These  facts  constitute  so  many  indications  for  the  regulation  of  our  surgical 
treatment.  While,  on  the  one  hand,  they  allow  us  within  certain  limits  to  count 
with  more  certainty  than  in  adults  upon  good  results  in  surgical  treatment,  and 
permit  us  to  follow  out,  further  than  in  adults,  the  trend  of  modern  surgery 
toward  conservative  methods,  on  the  other  hand  they  warn  us  against  pro- 
tracted operations  associated  with  loss  of  blood,  and  admonish  us  to  watch 
narcosis  with  a  jealous  eye,  to  give  special  care  to  the  selection  of  our  antisep- 
tics, and  to  modify  in  some  instances  our  methods  of  operation. 

These  general  principles  will  lead  us  to  certain  specific  precautions  in  the 
surgical  treatment  of  infants  and  children.  When  chloroform  is  to  be  adminis- 
tered, we  must,  not  allow  too  long  an  interval  of  fasting  to  precede  antesthetiza- 
tion,  lest  the  patient  begin  the  operation  faint  from  hunger.  Chilling  of  the 
body,  or,  indeed,  of  any  portion  of  it,  must  be  scrupulously  guarded  against,  and 
for  the  same  reason,  viz.,  on  account  of  the  effect  of  high  temperatures  upon  the 


774  AMERICAN  PRACTICE  OF  SURGERY. 

general  nutritive  processes  of  the  child,  no  operations  but  those  of  urgency 
should  be  undertaken  during  extremely  hot  weather.  Another  wise  prophylac- 
tic measure  intimately  affecting  surgical  prognosis  in  children,  especially  in  hos- 
pital inmates,  is,  according  to  the  suggestions  of  D'Arcy  Power,  to  delay  an 
operation  of  any  magnitude,  if  it  be  possible,  until  the  expiration  of  the  incuba- 
tion periods  of  those  exanthematous  diseases  from  which  the  child  has  not  yet 
suffered.  It  must  further  be  borne  in  mind  that  infants  are  extremely  susceptible 
to  interruptions  and  changes  in  diet,  and  that,  except  in  the  most  urgent  cases, 
it  is  well  not  only  to  correct  any  gastro-intestinal  irregularities  that  may  be 
present  in  an  infant  upon  whom  it  is  proposed  to  operate,  but  to  make  sure  also, 
by  actual  trial,  that  the  child  can  retain  and  digest  the  diet  on  which  it  is  pro- 
posed to  feed  it  after  the  operation. 

Save  in  most  urgent  cases  plastic  operations  are  not  best  performed  in  early 
infancy.  The  diminutive  size  of  the  parts  will,  in  many  operations,  add  greatly 
to  the  difficulty  of  their  execution,  will  enhance  the  difficulty  of  the  exact  hsemo- 
stasis  which  these  operations  demand  per  se,  and  which  is  furthermore  exacted 
by  the  small  body  weight  of  the  patient,  and  will  make  the  procedure  more  pro- 
longed and  relatively  more  severe  than  in  a  somewhat  older  child. 

Another  matter  to  be  thought  of  in  connection  with  plastic  operations,  and 
indeed  with  any  considerable  operation  in  the  infant,  is  the  difficulty  in  applying 
and  maintaining  surgical  dressings  in  the  infant,  and  of  keeping  such  dressings 
clean.  In  fact,  any  surgical  operation  demanding  prolonged  after-care  must  be 
considered  relatively  unfavorable  in  the  infant;  particularly  does  this  apply  to 
operations  on  or  near  the  natural  orifices  of  the  body. 

In  cases  where  it  is  possible  to  provide  properly  for  all  these  matters,  there 
are,  on  the  other  hand,  many  advantages  in  surgical  practice  among  infants. 
The  ready  depression  of  the  vital  forces  in  infancy  is  correlative  with  an  equally 
ready  recuperation.  Furthermore,  infants  are  relieved  of  the  depressing  effects 
of  anticipation.  As  the  infantile  sensoriuni  is  relatively  unimpressionable,  they 
bear  acute  (but  not  -protracted)  pain  relatively  well,  and  they  are  not  so  likely  to 
suffer  from  nervous  shock.  Many  operations  may  be  done  on  them  without  an 
anaesthetic,  and  the  condition  of  semi-ansesthesia,  so  perilous  in  the  administra- 
tion of  chloroform  in  adults,  is  relatively  much  less  dangerous  in  infants.  This 
is  fortunate,  because  local  anesthesia,  with  cocaine,  etc.,  is  hardly  applicable  in 
infantile  surgerj'. 

(b)  Childhood. — The  general  considerations  which  we  have  reviewed,  as  ap- 
plicable to  surgery  in  infancy,  become  less  and  less  applicable  as  the  age  of  the 
patient  increases.  The  main  distinction  between  infancy  (say  the  first  year  of 
life)  and  childhood  (say  the  ten  years  next  succeeding)  lies,  from  the  surgeon's 
point  of  view,  first,  in  a  slight  loss  of  the  advantages  of  the  energetic  cell  activity 
of  infancy ;  and  secondly,  in  a  more  than  compensating  gain  in  the  stability  of 
the  nutritional  processes  of  the  older  child  as  compared  with  those  of  the  infant ; 


GENERAL  SURGICAL  PROGNOSIS.  775 

while,  in  the  third  place,  there  is  a  marked  accentuation  in  the  impressionability 
of  the  sensorium;  and  fom-thly,  the  development  of  will  power  and  voluntary 
action  in  the  child  come  into  active  play. 

This  change  from  infancy  to  childhood  affects  surgical  prognosis  more  par- 
ticularly in  the  following  ways:  The  intractability  of  spoiled  children  may  so 
far  interfere  witli  examination  before  and  after  operation  and  hinder  the  carry- 
ing out  of  necessary  treatment  as  to  affect  seriously  the  prognosis  of  the  case. 
The  impressionability  of  the  sensorium  being  considerably  heightened,  nervous 
shock  is  more  common  and  the  patient  is  more  likely  to  be  favorably  or  unfavor- 
ably affected  by  his  environment.  While  confinement  to  bed  may  be  considered 
a  quasi-normal  condition  for  the  infant,  it  is  not  so  for  the  older  child,  and  chil- 
dren bear  confinement  to  bed  and  even  to  the  house  very  badly.  The  relative 
immunity  of  the  infant  to  certain  types  of  infection  grows  less  in  the  older  child, 
and  we  find  bone  disease  more  obdurate;  the  tendency  to  diseases  of  the  upper 
air  passages  (adenoid  growths,  etc.),  with  their  deleterious  effects  upon  nutri- 
tion, very  marked;  and  a  characteristic  vulnerability  of  the  lymphatics.  Still, 
as  compared  with  infants,  children,  when  these  obstacles  can  be  met  and  over- 
come, are  good  surgical  patients,  and,  in  view  of  their  comparatively  ready  re- 
sponse to  medication,  give  us  perhaps,  all  things  considered,  the  best  prognostic 
showing  of  any  age. 

The  progressive  increase  of  the  child  in  stature  brings  with  it,  however,  cer- 
tain surgical  restrictions  which  must  not  be  lost  sight  of.  The  growth  of  the 
long  bones  takes  place  at  the  epiphyseal  cartilages,  and  these  must  be  respected. 
Typical  joint  resections  are  therefore  inadmissible  in  infancy  and  childhood,  and 
amputations  in  continuity  will  almost  invariably  be  followed  by  a  conical  stump ; 
while  in  bone  disease  involving  the  destruction  of  the  epiphyseal  cartilage,  the 
prognosis  as  to  the  future  development  of  the  limb  is  distinctly  bad. 

While  the  pathogenesis  of  lardaceous  or  amyloid  disease  is  not  sufficiently 
well  determined  to  enable  us  to  assert  a  connection  with  the  vulnerability  of  the 
lymphatic  system  which  we  have  noted  as  characteristic  of  childhood,  yet  the 
fact  is  observed  that  chronic  debilitating  diseases,  and  particularly  chronic  sup- 
purations, are  prone  to  be  followed  by  this  sequel  in  childhood. 

(c)  Adolescence. — Three  factors  influence  general  prognosis  in  adolescence. 
They  are,  first,  a  supreme  impressionability  of  the  sensorium,  so  that  at  this  age 
the  entourage  of  the  patient  acquires  increased  prognostic  import;  secondly,  the 
liability  to  blood  dyscrasige,  especially  secondary  angemias;  thirdly,  a  passing 
off  of  the  relative  immunity  of  infancy  and  childhood,  so  that  diseases  become 
more  readily  chronic,  and  chronic  diseases,  particularly  bone  diseases,  exhibit  a 
sometimes  disheartening  obstinacy. 

(d)  Maturity.— In  considering  the  prognostic  import  of  age  as  bearmg  upon 
patients  in  that  period  of  life  which  we  call  maturity,  full  sexual  development 
must  be  discounted  in  both  sexes,  and,  with  this,  the  liability  of  the  patient  to 


776  .-UIERICAX  PRACTICE   OF  SURGERY. 

chronic,  perhaps  concealed  or  unknown  venereal  mfection.  Sexual  excesses  and 
abnormalities  have  also  an  effect  upon  general  prognosis.  It  is  in  this  period  of 
life  that  cares,  responsibilities,  and  burdens  rest  most  hea^alj^  upon  us,  and  con- 
sequent netirasthenia,  actual  or  potential,  is  of  marked  prognostic  import. 
Chronic  gastric  or  intestinal  catarrhs  may  so  affect  general  bodily  nutrition  as 
to  compromise  gravelj'  a  prognosis  otherwise  good,  and  the  so-called  ''dyspep- 
sias" are  most  frequent  in  middle  age.  The  diatheses  rise  from  latencj-  to  ac- 
tivity diu-ing  this  period  of  life,  and  alcohol,  morphine,  tobacco,  or  other  drugs 
may  be  exercising  a  chronic  depressing  influence  upon  the  vitality  of  the  patient. 
The  exalted  activity  of  the  cellular  processes  of  infancj^  has  spent  itself,  and  the 
middle-aged  man  or  woman  has  lost  the  attendant  relative  immunity  of  the  in- 
fant and  the  child,  but  carries  perchance  instead  the  burden  of  many  conflicts 
with  invasive  micro-organisms,  which,  while  won,  may  yet  have  left  in  the  pa- 
tient depletion  or  debility  as  the  price  of  \actor3^ 

(e)  Senility. — Old  age  is  the  period  when  the  various  systems  and  processes 
of  the  economy  begin  to  lose  their  normal  balance,  and  atrophic  and  involutive 
processes  give  rise  to  certain  characteristic  conditions  which  are  of  prognostic 
significance.  Of  these  perhaps  the  most  important  is  the  condition  of  the  heart 
and  of  the  blood-vessels,  and  the  normal  balance  between  their  respective  func- 
tions. We  have  seen  how  dependent  upon  a  generous  blood  supplj*  was  the 
active  cellular  metabolism  of  infancy;  scarceh'  less  sensitive  to  the  abimdance 
and  regularitj-  of  the  blood  supply  are  the  tissues  of  the  aged,  in  whom  a  con- 
stitutional condition  bordering  upon  a  d}'stroph3^  is  to  be  expected,  so  that 
impau-ment  of  blood  supph^  and  disturbances  of  inner\^ation  react  similarly 
upon  the  infantile  and  upon  the  senile  organism.  It  is  on  account  of  theu  effect 
upon  the  nutritive  processes  of  the  senile  tissues  that  chilling  of  the  body  dm-ing 
operations  upon  the  aged  must  be  scrupuloush^  avoided;  and  so  likewise  any 
rough  handling  of  the  tissues  by  ill-conducted  manipulation.  Special  pains 
must  be  taken  in  the  aged  to  avoid  increasing  the  intravascular  pressm-e,  for 
fear  of  apoplectic  accidents.  Although  the  aged  bear  hemorrhage  badly,  the 
same  absolute  loss  of  blood  in  ounces,  inasmuch  as  it  bears  a  less  proportion  to 
the  total  body  weight,  will  probably  be  less  injurious  than  in  the  infant.  On  the 
other  hand,  the  diminished  elasticity  of  the  senile  vascular  sj'stem  allows 
capillary  hemorrhage  to  continue  longer  than  in  j'ounger  patients — a  considera- 
tion of  special  moment  in  plastic  operations  and  where  large  wounds  are  in 
question,  with  extensive  flaps. 

The  bronchial  and  pulmonarj*  conditions  of  the  aged  have  an  important 
bearing  on  the  prognosis  of  such  cases  as  maj'  requh'e  a  general  antesthetic,  be- 
cause the  chronic  bronchitis  so  prevalent  in  them,  and  the  emphysema  with 
which  it  is  apt  to  be  associated,  are  so  readity  exalted  to  the  condition  of  bron- 
cho-pneumonia. 

The  diminished  impressionabilitj^  of  the  sensorimn  in  the  aged  is  a  factor 


GENERAL  SUEGICAL  PROGNOSIS.  777 

favorable  on  the  whole  hi  prognosis.  It  dimmishes  the  tendency  to  nervous 
shock,  and  it  might  even  ui  some  cases  allow  operations  ui  the  condition  of  semi- 
antesthesia,  recognized  to  be  so  perilous  in  any  but  the  extremes  of  life. 

Another  characteristic  senile  change  is  of  importance  as  regards  surgical 
prognosis,  viz.,  the  atrophic  condition  of  the  skin.  This  affects  seriously  the 
chances  of  primary  imion  in  operative  cases,  and  retards  greatly  the  healing  of 
accidental  abrasions,  contusions,  lacerations,  and  other  traumata  involving 
the  cutaneous  and  subcutaneous  tissues.  Its  bearing  upon  the  prognosis  of  ex- 
tensive plastic  operations  in  the  aged  is  obvious. 

Old  people  do  not  bear  well  confinement  in  bed.  The  development  of  bed- 
sores is  hard  to  prevent,  and-  they  are  of  obstinate  and  often  dangerous  character 
when  they  occur.  They  are  due  to  atrophy  of  the  skin,  to  the  absorption  of  the 
cushion  of  subcutaneous  fat,  to  the  degeneration  of  the  blood-vessels,  and  to 
muscular  debility  preventing  them  from  moving  readily  in  the  bed. 

Yet  senility  is  meastned  not  alone  by  the  years  of  the  patient.  Man  has 
been  said  to  be  as  old  as  his  arteries,  and  the  relative  prognosis  of  a  surgical' 
case  in  old  age  will  depend  upon  the  degree  of  senile  involution  presented  by  the 
patient.  Senile  affections  of  the  heart,  the  blood-vessels,  and  the  lungs  are  the 
most  important. 

The  aged  offer  but  feeble  resistance  to  microbial  invasion,  but  under  rigid 
asepsis  modern  surgery  on  aged  subjects  has  furnished  results  surprisingly  favor- 
able, particularly  in  the  surgery  of  those  pitiable  sufferers  from  prostatic  hyper- 
trophy, where  ample  drainage  and  careful  asepsis  have  brightened  the  declining 
years  of  hundreds,  whom  a  too  timid  distrust  of  the  prognosis  in  surgical  pro- 
cedure on  the  aged  would  have  abandoned  to  the  miseries  of  "catheter  life." 

II.  Sex. 

As  suggested  above,  the  sex  of  the  patient  concerns  more  closely  the  inci- 
dence than  it  does  the  prognosis  of  surgical  diseases.  Yet  many  surgeons  are 
convinced  of  the  greater  powers  of  passive  endurance  in  women.  This,  indeed, 
is  in  conformity  with  a  tendency  which  nature  shows  in  the  females  of  other  ani- 
mal species.  A  matter  bearing  weight  in  that  direction,  at  least  in  this  coimtry, 
is  the  less  addiction  of  women  to  alcoholism  and  other  excesses  too  readily  in- 
dulged .in  by  men.  To  offset  this  is  a  proneness  to  chlorotic  and  anaemic  condi- 
tions, which  is  more  marked  in  women  than  in  men. 

But  to  pass  from  indefinite  tendencies  to  more  specific  matters,  we  have  to 
consider  for  a  moment  the  effect  upon  prognosis  of  the  arbitrary  neutralization 
of  sex  by  castration.  Unfortunately  the  data  available  on  this  point  are  few, 
and  I  cannot  do  much  more  than  to  call  the  reader's  attention  to  this  as  a  pos- 
sible factor  in  prognosis.  Early  castrates  of  either  sex  are  rare.  No  statistics, 
so  far  as  I  know,  are  available  as  to  the  general  powers  of  resistance  of  oopho- 
rectomized  women  as  compared  with  those  of  their  more  forttmate  sisters. 


778  AMERICAN  PRACTICE  OF  SURGERY. 

Though  we  are  not  considering  the  prognosis  of  the  operation  of  castration  per 
se,  which  belongs  to  the  domain  of  special  as  opposed  to  that  of  general  progno- 
sis, yet  it  is  to  be  observed  that  the  importance  of  the  generative  glands  upon 
the  general  vital  processes  has  been  made  strikingly  evident  since  the  studies 
provoked  by  Bro-mi-S^quard's  experiments  (with  orchitic  extracts),  and  more 
recently  by  the  ill  effects  attending  castration  as  a  relief  for  "prostatism"  at 
an  age  when  the  generative  glands  might  be  supposed  to  have  but  a  diminished 
influence  upon  the  general  metabolism  of  the  individual. 

What  I  have  to  offer  further  upon  this  subject  of  the  relation  of  sex  to  sur- 
gical prognosis  concerns  exclusively  the  sexual  functions  of  women — menstrua- 
tion, pregnancy,  abortion,  parturition,  lactation,  and  the  phenomena  of  the 
climacteric;  and  the  consideration  of  these  questions  will  lead  us  to  adopt  a 
reciprocal  method  of  discussion,  one  to  which  we  shall  have  frequent  occasion  to 
return  in  the  course  of  this  study,  viz.,  the  investigation,  first,  of  the  impres- 
sion of  these  several  functions  upon  the  course  of  surgical  diseases;  and  then, 
reciprocall}',  the  impression  exercised  by  surgical  procedures  upon  these  several 
functions. 

(a)  Menstruation. — As  to  menstruation,  if  the  old  theorj^  of  its  being  the  re- 
sult of  a  general  plethora  had  been  true,  it  might  have  been  conceived  to  have  a 
favorable  prognostic  value  with  regard  to  the  nutrition  of  the  tissues  in  connec- 
tion with  surgical  operations ;  as  a  matter  of  fact,  however,  menstruation,  when 
normally  performed,  has  but  slight  influence  upon  prognosis.  This  much,  how- 
ever, may  be  admitted,  that  with  normal  menstruation  it  is  not  uncommon,  in 
cases  of  critical  illness,  to  see  improvement  apparently  stimulated  on  the  ap- 
pearance of  the  menstrual  flow. 

It  has  been  my  habit,  in  operations  of  election  upon  women,  to  choose  a  time 
a  few  days  after  the  close  of  the  menstrual  period,  with  a  view  of  eliminating 
any  possibly  unfavorable  effect  of  menstruation  as  a  complication,  till  such  a 
time  as  the  patient  might  be  expected  to  be  beyond  the  critical  stage  of  recov- 
ery ;  and  this  in  operations  other  than  those  upon  the  reproductive  organs.  In 
gynjecological  operations  proper  this  plan  would  seem  to  be  the  more  entitled  to 
consideration. 

On  the  other  hand,  with  regard  to  the  reciprocal  effect  of  an  operation  per  se 
upon  the  function  of  menstruation,  this  may  be  said:  that  the  effect  of  a  major 
extra-genital  operation  is  variable  and  can  hardly  be  predicted.  It  may  hasten 
menstruation  by  a  few  days  (perhaps  the  most  common  effect),  or  indeed  pre- 
cipitate it  immediately;  it  may  retard  its  appearance  by  a  few  days  or  weeks, 
or  indeed  cause  its  suppression  for  one  or  more  periods;  or  (as  frequently  hap- 
pens) it  may  not  exert  any  traceable  effect  upon  that  fimction. 

(b)  Pregnancy. — The  question  of  pregnancy  in  its  effect  upon  general  sur- 
gical prognosis  is  as  hard  to  estimate  as  that  which  we  have  just  been  consider- 
ing.    In  early  pregnancy  the  intractable  vomiting  which  this  condition  some- 


GENERAL  SURGICAL  PROGNOSIS.  779 

times  induces  may  be  a  factor  of  great  importance.  In  advanced  pregnancy  the 
tendency  to  eclampsia  merits  consideration,  particularly  in  primiparje,  and  so 
likewise  the  interference  with  proper  respiration  occasioned  by  the  mass  of  the 
pregnant  uterus  in  the  abdomen. 

In  operations  upon  the  abdominal  wall  the  severe  strain  upon  the  cicatrix 
must  be  borne  in  mind,  especially  in  operations  for  ventral  and  imibilical  hernia. 

Strangulation  of  inguinal  and  femoral  hernige,  due  to  the  pressure  of  the 
gravid  uterus,  does  not  seem  to  occur  with  any  such  frequency  as  might  a  priori 
have  been  expected,  especially  when  we  consider  the  difficulty  or  even  impos- 
sibility of  retaining  the  hernia3  with  a  truss  during  the  latter  part  of  gestation. 
As  to  the  effect  of  pregnancy  upon  neoplasms  connected  with  the  reproductive 
organs,  whether  the  breasts  or  the  pelvic  organs,  it  is  well  kno'WTi  to  cause  a 
great  acceleration  in  their  growth.  Pregnancy  occasionally  will  greatly  retard 
the  process  of  calcification  in  the  healing  of  bony  fractures,  and  it  is  said  that 
newly  healed  fractures  may  even  lose  their  recently  deposited  calcium  salts  upon 
the  supervention  of  pregnancy.  The  disastrous  effect  of  pregnancy  upon  osteo- 
malacia has  been  repeatedly  observed.  The  debility  arising  from  too  frequently 
recurring  pregnancy  can  best  be  considered  as  a  phase  of  neurasthenia. 

The  reciprocal  of  the  cpestion  of  the  effect  of  pregnancy  upon  surgical  dis- 
eases is  that  of  the  effect  of  sm'gical  diseases  and  operations  upon  pregnancy; 
that  is,  the  likelihood  of  their  producing  abortion.  Upon  this  question  some 
interesting  and  instructive  data  are  available,  showing  us  the  remarkable  toler- 
ance exhibited  by  the  pregnant  titerus  in  the  face  of  operative  procediu'es  of 
considerable  magnitude,  even  when  directed  to  the  reproductive  organs,  to  the 
immediate  uterine  appendages,  and,  mirabile  dictu,  to  the  uterus  itself. 

Thus  Gordon  *  relates  the  case  of  the  removal  of  a  sessile  uterine  fibroid, 
nearly  as  large  as  the  uterus  itself,  done  at  the  third  month  of  pregnancy,  with- 
out interrupting  the  pregnancy  or  apparently  affecting  delivery  at  the  comple- 
tion of  the  period  of  gestation ;  and  Sylvester  t  removed,  in  the  third  month  of 
pregnancy,  a  uterine  fibroid,  weighing  eight  and  three-quarter  pounds  and  hav- 
ing a  pedicle  two  inches  in  diameter,  with  normal  delivery  of  a  living  child  at 
term. 

Breast  amputations  are  related  as  late  as  the  sixth  and  seventh  month,  also 
trachelorrhaphy;  and  one  man  J  vouches  for  the  dilatation  of  the  internal  os 
(sic)  for  the  relief  of  hyperemesis,  all  without  causing  abortion  or  miscarriage. 
Oophorectomy  has  been  repeatedly  performed  during  pregnancy,  and,  according 
to  A.  P.  Dudley,§  if  it  causes  miscarriage  it  does  so  only  by  hemorrhage  into  the 
uterus,  which  on  this  account  should  be  scrupulously  guarded  against.    Yet  the 

*  Gordon:   Trans.  Maine  Med.  Assoc,  1889,  vol.  10,  pp.  99-104. 

t  Sylvester:   New  England  Med.  Gazette  (HomcEop.),  Boston,  1890,  vol.  25,  p.  397. 

i  Trans.  Maine  Med.  Assoc,  loc.  cit. 

S  Trans.  Maine  Med.  Assoc,  loc.  dt. 


7S0  .\3IERIC-\X   PRACTICE   OF   SURGERY. 

fact  remains  that  a  considerable  number  of  abortions  do  occm-  after  even  extra- 
genital major  operations,  and  that  pehdc  and  abdominal  operations  are  particu- 
larly likely  to  induce  this  accident.  This  may  be  due  in  part  to  the  death  of  the 
foetus  by  intoxication  from  the  anaesthetic  rather  than  to  the  operation  per  se; 
hence  the  recommendation  to  elect  ether  in  preference  to  chloroform  in  these 
cases,  as  being  less  noxious  to  the  foetus. 

(c)  Parturition. — The  prognostic  importance  of  parturition  relates  to  its 
effect  upon  certain  few  smgical  conditions,  of  which  hernia  on  the  one  hand, 
and  aneurisms  and  varices  and  certain  ocular  and  cerebral  conditions  on  the 
other  hand,  are  perhaps  the  chief.  Tliese  have  in  common  an  intimate  depend- 
ence upon  the  effects  of  the  powerful  contraction  of  the  uterine  and  abdominal 
muscles,  and  the  resultant  intra-abdominal  pressm^e,  either  directly,  as  in  her- 
nia, or,  as  in  the  other  conditions,  through  the  effect  of  these  voluntary  and  in- 
volvmtarj'  musciolar  contractions  upon  the  blood  pressm-e. 

In  labor,  as  dming  pregnancy,  though  tlie  effect  of  these  factors  upon  hernia 
must  be  regarded  as  unfavorable,  j^et  accidents  of  strangulation  are  very  rarely 
reported  in  medical  literatm-e.  For  anem-isms  and  varices,  as  well  as  the  other 
ocular  and  intracranial  conditions  alluded  to,  the  peril  may  be  said  to  be  directly 
proportional  to  the  blood  pressm-e,  and  maj-  make  the  earty  use  of  anaesthesia 
and  the  prompt  resort  to  instrumental  deliverj'^  imperative.  It  is  the  province 
of  special  prognosis  to  consider  the  outcome  of  the  partmient  act  itself,  and 
likewise  to  take  cognizance  of  its  effect  upon  the  uterus  and  the  perineum,  which 
may  or  maj-  not  have  been  the  seat  of  pre^dous  plastic  operations. 

(d)  Lactation. — Lactation,  except  the  effects  of  too  prolonged  lactation 
which  are  substantially  those  of  neurasthenia,  is  of  prognostic  importance  chiefly 
in  proposed  operations  upon  the  breasts.  Their  marked  increase  of  blood  supply 
dm-ing  this  period  makes  the  danger  of  troublesome  hemorrhage  somewhat 
greater. 

(e)  The  Climacteric. — As  to  the  effects  of  the  climacteric  upon  the  general 
nervous  system,  they  are  likewise  substantially  those  of  neurasthenia,  and  but 
one  important  factor  concerns  us  here,  viz.,  the  effect  of  the  menopause  upon 
neoplasms.  The  onlj-  case  in  which  its  advent  can  be  considered  to  have  a  favor- 
able effect  is  in  that  of  uterine  fibroids.  In  this  case,  while  tmdoubtedly  a  con- 
siderable number  of  tumors  of  that  class  cease  to  be  troublesome  after  the  estab- 
lishment of  the  menopause,  j^et  this  advantage  is  greatly  offset  bj'  the  tendency 
of  these  neoplasms,  as,  indeed,  of  many  other  forms  of  new  growth,  to  imdergo 
malignant  degeneration  at  this  period  of  life. 

III.    COXSTITUTIOX. 

In  a  certain  sense  the  term  "constitution"  is  the  summation  of  all  the  ele- 
ments of  our  present  studj-,  as  age,  sex,  disease,  etc.,  are  but  factors  making  up 
the  constitution  of  the  individual.    In  a  more  limited  sense,  however,  we  may 


GENERAL  SURGICAL  PROGNOSIS.  781 

consider  the  constitution  of  the  individual  to  be  that  original  fund  of  vitality 
and  capacity  to  resist  and  overcome  disease  with  which  his  temperament,  his 
diathesis,  his  personal  heredity,  and  his  race  have  endowed  him. 

(a)  Temperament.— The  consideration  of  temperament  has  so  far  gone  out 
of  fashion  that  even  the  terms  in  which  it  was  discussed  are  now  no  longer  com- 
prehended. The  conception  of  the  four  principal  temperaments— the  sanguine, 
the  nervous,  the  bilious,  and  the  lymphatic— was  doubtless  the  product  of  more 
or  less  fanciful  reasoning  upon  erroneous  data  of  the  old  humoral  pathology. 
Nevertheless,  there  are  certain  mental,  moral,  and  physical  characteristics 
which  present  themselves  in  certain  groups  of  individuals,  and  these,  taken  as  a 
whole,  have  an  appreciable  influence  upon  such  surgical  diseases  and  conditions 
as  may  affect  the  members  of  that  group.  The  sanguine  temperament,  fair- 
haired,  blue-eyed,  with  energetic  movements,  may  not  in  its  pm-e  type  have  a 
special  prognostic  coefficient  of  its  own,  yet  it  is  possible  to  select,  according  to 
some  more  or  less  vague  criterion,  groups  of  individuals  of  whom,  though  they 
be  all  at  the  moment  in  equally  good  health,  it  will  be  possible  to  predicate  that 
these,  by  temperament  and  constitution,  have  a  better  chance  to  recover  than  " 
have  those  from  equally  grave  surgical  diseases  and  conditions.  In  these,  call 
their  temperament  sanguine  or  nervous,  as  you  will,  we  can  count  upon  the  pa- 
tients to  co-operate  with  the  surgeon  to  achieve  their  own  recovery — they  make 
"good  patients";  while  in  those  it  is  recognized  that,  call  their  temperament 
what  you  will,  bilious  or  lymphatic,  the  prognosis  is  relatively  imfavorable,  and 
they  may  succumb  from  sheer  inability  to  summon  the  forces  of  recuperation. 
The  first  have  warm  extremities,  active  circulation,  and  energetic  movements; 
the  second  have  cold  hands  and  feet,  muddy  or  pale  complexion,  and  sluggish 
movements.  However  vague  these  conceptions  are,  they  have  a  certain  undeni- 
able prognostic  weight. 

(b)  Diathesis. — The  vagueness  of  our  conception  of  temperament  is  slightly 
relieved  when  to  it  we  add  the  likewise  indefinite  conception  of  diathesis.  A 
proper  mingling  of  temperament  and  diathesis  gives  us  the  well-recognized  type 
known  as  the  "habitus  phthisicus."  Now,  though  we  are  dealing  with  confess- 
edly shadowy  and  indefinite  quantities  when  we  discuss  temperament  and  di- 
athesis, yet  a  little  attention  will  bring  to  the  fore  one  important  rule  of  prog- 
nosis, to  wit,  where  the  incidence  of  disease  corresponds  to  well-marked  tempera- 
ment and  diathesis,  the  prognosis  is  relatively  unfavorable.  For  instance,  the 
concurrence  of  surgical  tuberculosis  and  the  "habitus  phthisicus"  adds  greatly 
to  the  gravity  of  the  prognosis;  the  "dartrous"  diathesis,  coupled  with  the 
sanguine  or  the  lymphatic  temperament,  together  constitute  a  type  in  whom 
ulcerative  processes  will  be  found  exceptionally  obstinate ;  those  of  bilious  tem- 
perament and  of  the  gouty  diathesis  will  have  calculous  troubles  of  greater 
gravity  than  will  members  of  the  other  groups,  should  the  inciting  factors  of 
calculus  formation  present  themselves.    Yet  ulcers  heal  kindly  in  those  of  the 


782  AMERICAN   PRACTICE   OF   SURGERY. 

phthisical  habit ;  those  of  the  sanguine  or  the  l3anphatic  temperament  and  with 
a  tendency  to  dartrous  manifestations  are  less  likely  to  have  grave  symptoms 
from  calculi;  and  those  of  bilious  or  nervous  temperament  with  a  gout}'  diath- 
esis are  so  far  immune  to  tuberculosis  that  if  it  should  establish  itself  the  prog- 
nosis is  far  better  than  in  those  of  the  first  group. 

Our  modern  knowledge  of  the  role  of  micro-organisms  in  the  causation  of 
disease  leads  us  to  overlook  much  that  was  of  value  in  the  keen  observations  of 
our  fathers.  So  much  have  microscopy  and  the  so-called  "  laboratory  methods" 
of  diagnosis  occupied  the  modern  physicians,  that  little  scientific  study  has  been 
devoted  to  the  analysis,  deliniitation,  and  classification  of  diatheses.  There  is 
vaguely  recognized  by  the  profession  of  to-day  a  gouty  (or  arthritic  or  lith^pmic) 
diathesis,  and  the  studies  of  Bouchard  tend  to  group  this  and  certain  other 
morbid  tendencies  under  the  head  of  troubles  due  to  defective  oxygenation  or 
hypometabolism.  It  seems  to  be  acknowledged  that  the  gouty  diathesis  is 
likely  to  entail  upon  its  subjects  arteriosclerosis  and  chronic  nephritis,  and  these 
would  have  a  decided  prognostic  significance  in  surgery,  inasmuch  as  tempo- 
rary urinary  inadequacy  may  easily  be  a  sequel  to  anaesthesia  or  even  to  simple 
surgical  shock.  One  other  diathesis  has  acquired  tolerably  distinct  recognition, 
viz.,  the  neuropathic;  and  it  is  likewise  possible  to  establish  as  a  fairly  distinct 
entity  the  obese  diathesis.  One  important  bearing  of  this  latter  upon  surgical 
prognosis  is  with  reference  to  its  effect  upon  the  heart,  whose  function  may  be 
greatly  impeded  by  massy  deposits  of  fat  and  by  fatty  infiltrations  of  the  myo- 
cardium. A  second  consideration  is  the  thickness  of  the  subcutaneous  pannic- 
ulus,  with  its  heavy  mass  of  tissue  of  low  vitality,  prone  to  suffer  the  invasion  of 
pyogenic  germs.  A  third  is  the  possibility  of  fat  embolism,  when  it  is  necessary 
to  work  in  great  adipose  masses,  e.g.,  in  deligation  of  the  omentum. 

In  general,  good  bodily  development,  large  bones,  hard  muscles,  little  fat,  yet 
good  body  weight,  and  a  history  of  freedom  from  previous  disease — these  are 
the  indications  of  a  good  constitution,  irrespective  of  temperament  or  diathesis. 

(c)  Heredity. — Wlien  we  pass  from  the  consideration  of  temperament  and 
diathesis  to  that  of  heredity,  Ave  come  upon  a  more  stable  footing,  and,  though 
the  subject  is  one  of  infinite  complication  and  dispute,  yet  certain  facts  are 
sufficiently  clear  to  have  a  distinct  bearing  upon  prognosis.  For  the  most  gen- 
eral of  these  facts  concerning  heredity  we  are  indebted  to  the  observations  and 
records  of  life-insurance  examiners,  who  have  demonstrated  the  highly  influ- 
ential distinction  between  long-lived  families  and  short-lived  families.  The 
effect  of  this  hereditary  characteristic  upon  surgical  prognosis  is  very  obvious, 
and  at  the  same  time  very  considerable. 

Of  secondary  unportance  m  their  influence  upon  surgical  prognosis  are  syph- 
ilis, rheumatism,  gout,  tuberculosis,  alcoholism,  obesity,  diabetes,  nephritis, 
cancer,  insanity,  and  epilepsy  in  the  parents.  Although  the  common  effect  of 
all  these  parental  diseases  is  to  impart  to  the  offspring  a  weakened  constitution. 


GENERAL  SURGICAL  PROGNOSIS.  783 

yet  bad  heredity  for  one  disease  may  not  be  bad  heredity  for  all;  e.g.,  a  gouiy 
heredity  is  rather  favorable  than  otherwise  in  the  prognosis  of  surgical  tuber- 
culosis. 

Heredity  may  determine,  however,  more  than  a  mere  feeble  resistance  to 
disease.  It  may  determine  a  distinct  locus  minoris  resistentice,  stomach,  liver, 
uterus,  and  skin  showing  respectively  an  inherited  tendency  to  the  localization 
of  disease  upon  these  particular  organs. 

The  heredity  of  malignant  diseases  may  come  under  both  these  categories ; 
i.e.,  the  transmission  of  the  tendency  to  specific  forms  of  disease,  and  the  trans- 
mission of  the  tendency  to  the  involvement  of  a  particular  organ.  One  question 
which  suggests  itself  in  this  connection  I  am  not  able  to  answer  for  want  of  sta- 
tistics, viz.,  whether  malignant  disease  shows  an  enhanced  malignity  in  those 
predisposed  by  heredity  as  compared  with  those  not  so  predisposed. 

We  have  stated  it  above  as  a  law  that  the  concurrence  of  temperament  and 
diathesis  with  the  incidence  of  disease  is  markedly  unfavorable  upon  prognosis. 
When  to  this  triad  there  is  added  a  fourth  factor,  viz.,  heredity,  the  prognosis 
becomes  still  more  unfavorable;  as  is  illustrated  in  the  case  of  tuberculosis, 
where,  when  this  disease  fastens  upon  one  of  the  phthisical  habit,  a  tuberculous 
family  history  adds  appreciably  to  the  gravity  of  the  prognosis. 

The  most  patent  illustration  of  the  effect  of  heredity  upon  disease  is  seen  in 
the  case  of  hereditary  hsemophilia,  with  its  well-loiown  transmission  of  hemor- 
rhagic tendency  through  the  female  line. 

(d)  Race. — The  simimation  of  hereditary  influences  is  to  be  seen  in  the 
problems  of  race.  Surgical  prognosis  in  mulattoes,  as  indeed  in  most  mixed 
races,  is  certainly  relatively  unfavorable. 

Concerning  the  African  negroes  of  full  blood,  it  may  be  affirmed  that,  at  least 
in  the  savage  state,  their  less  highly  developed  nervous  system  renders  them 
comparatively  insensible  to  pain  and  shock.  Bordier  *  is  the  authority  for  the 
statement  that  among  the  Yoloffs  it  is  a  not  uncommon  practice  to  rip  the  ab- 
domen open  and  handle  the  protruded  bowels,  with  a  view  of  testing  the  virtue 
of  the  "gri-gris"  given  by  an  itinerant  marabout,  and  then  return  the  exposed 
entrails  into  the  abdominal  cavity  with  apparent  unconcern.  This  is  surely  con- 
vincmg  not  only  of  the  lesser  sensibility  of  these  people  to  pain,  but  also  indicates 
a  greater  immunity  from  the  usual  dangers  of  peritoneal  infection.  Similar  facts 
can  be  quoted  with  regard  to  aboriginal  tribes  of  this  country,  for  instance,  the 
Modocs.  This  combmation  of  circumstances— i.e.,  a  naturally  diminished  pe- 
ripheral sensibility,  coupled  with  a  more  passive  condition  of  the  mind— makes 
the  negro  a  most  favorable  subject  for  all  kinds  of  surgical  treatment  with  or 
without  preliminary  anajsthesia.  Similar  testimony  is  offered  by  medical  mis- 
sionaries concerning  the  Asiatics  of  the  Pacific  littoral. 

*  Bordier,  quoted  in  article  by  Matas  on  "Surgical  Peculiarities  of  the  Negro,"  in  Dennis's 
"System  of  Surgery,"  vol.  4,  p.  847. 


784  AMERICAN  PRACTICE   OF  SURGERY. 

The  greater  immunity  formerly  enjoyed  by  the  negro  in  respect  of  certain 
diseases  is  rapidly  disappearing,  and  he  now  not  only  shares  the  physical  weak- 
nesses of  the  white  race,  as  exliibited  on  this  continent,  but  is  rapidly  developing 
previouslyunknown  predispositions,  which  are  increasing  his  general  tribute  to 
disease  and  death  even  to  a  more  fatal  degree  than  in  the  white  race.*  In  one 
particular  we  must  consider  further  the  influence  of  race  upon  surgical  prognosis, 
viz.,  with  regard  to  plastic  surgery  in  the  negro.  The  racial  tendency  to  keloid 
growths  in  cicatrices  must  always  be  borne  in  mind  in  planning  operations  of 
this  description  upon  negro  subjects. 

IV.  Integrity  of  Organs  and  Functions. 

In  considering  the  general  prognosis  of  surgical  diseases  and  conditions,  great 
stress  must  be  laid  upon  the  integrity  of  organs  and  functions,  and  on  the  exist- 
ence of  concomitant  disease.  This  important  factor  meets  us  in  all  questions  of 
surgical  prognosis,  whether  we  are  considering  treatment,  or  exploration,  or  the 
mere  duration  of  life  in  a  hopelessly  compromised  case.  Evidently  to  consider 
this  division  of  our  subject  with  anything  bordering  on  exhaustiveness  would 
call  for  an  elaborate  review  far  exceeding  the  limits  of  our  chapter,  and  we  can 
touch  here  only  on  certain  limited  phases  of  the  subject.  Instead  of  taking  up 
seriatim  the  maladies  from  which  the  surgical  patient  can  suffer  in  any  of  his 
organs,  I  propose  to  consider  but  a  few  of  these,  and  to  consider  them  in  their 
application,  first,  to  anaesthesia,  and  secondly,  to  surgical  operations  proper, 
leaving  the  rest  to  be  considered  elsewhere  in  this  work,  under  the  special  prog- 
nosis of  the  several  surgical  diseases,  conditions,  and  procediu'es  there  discussed, 
or  considering  them  to  have  received  already  sufficient  general  consideration  in 
the  pi'eceding  paragraphs. 

The  first  part  of  the  subject  may  perhaps  be  most  simply  considered  in  an 
attempt  to  answer  the  question.  What  morbid  conditions  render  the  administra- 
tion of  a  general  anesthetic  especially  dangerous?  while,  for  the  second  part,  we 
shall  attempt  fo  answer  the  question,  What  are  the  morbid  conditions  which 
especially  enhance  the  dangers  of  surgical  operations  per  set  Some  few  ques- 
tions properly  concerning  general  prognosis  which  do  not  come  under  this 
scheme  we  shall  touch  upon  briefly  at  the  close  of  this  section. 

1.  What  Morbid  Conditions  Render  the  Administration  of  a  General  An- 
aesthetic Especially  Dangerous? — In  many  sm-gical  procedures — indeed,  it  is 
safe  to  say  in  the  majority  of  aseptic  operations,  major  and  minor — the  chief 
danger  to  the  patient  lies  in  the  administration  of  chloroform  or  ether  for  the 
purpose  of  ansesthetization.  It  is  well  known  that  certam  diseases  of  the  heart 
and  blood-vessels,  certain  diseases  of  the  kidneys,  certain  diseases  of  the  lungs 
and  bronchi,  and  certain  morbid  conditions  of  the  nervous  system  render  an- 
esthetization extra-hazardous.    Let  us  examine  these  facts  more  closely. 

*  Matas,  loc.  cit. 


GENERAL  SURGICAL  PROGNOSIS.  785 

(o)  Cardiac  and  Vascular  Diseases. — The  chief  dangers  in  anaesthesia  come 
from  sinking  of  the  blood  pressure.  The  causes  which  occasion  this  are  obviously 
three — acute  hemorrhage,  cardiac  insufRciency,  and  general  or  extensive  local 
vasomotor  paresis. 

So  obvious  is  the  effect  of  acute  hemorrhage  that  we  need  do  no  more  than 
mention  it.    It  is  within  the  experience  of  every  anaesthetist. 

With  regard  to  cardiac  insufficiency,  it  may  be  said  that,  contrary  to  earlier 
teaching,  fully  compensated  vahailar  heart  disease  is  not  so  much  to  be  dreaded 
by  the  anaesthetist  as  to  call  for  anything  more  than  a  little  extra  care  in  the 
administration  of  the  anaesthetic.  Valvular  disease  with  under-compensation  is 
a  condition  of  greater  gravity,  though,  except  in  cases  of  aortic  stenosis,  the  sit- 
uation is  measurably  relieved  by  the  depletion  afforded  by  the  operative  incision. 

The  actual  functionating  of  the  organ  is,  after  all,  what  counts,  and  a  heart 
acutely  dilated  by  overexertion,  or  constantly  overstimulated  by  alcohol,  or 
driven  to  undue  frequency  of  rhythm  by  thyroidal  or  sympathetic  disturb- 
ances, or  weakened  in  its  myocardiimi  by  the  toxins  of  acute  disease,  presents 
perils  for  anaesthesia  quite  as  considerable  as  those  attending  an  obstructive  or 
regurgitant  lesion  of  the  cardiac  valves.  It  does  not  appear  that  mere  cardiac 
arrhythmia,  such  as  follows  chronic  abuse  of  coffee  or  tobacco,  the  "irritable 
heart"  which  causes  so  much  distress  and  alarm  to  its  subjects,  is  of  great  con- 
cern in  the  prognosis  of  anaesthesia,  though  it  may  well  be  that  the  well-recog- 
nized perils  of  semi-ana;sthesia,  through  its  tendency  to  inco-ordination  of  the 
reflexes,  are  greater  in  those  subject  to  these  functional  troubles  of  the  heart. 

The  most  exquisite  picture  of  general  vasomotor  paresis  is  seen  in  surgical 
shock,  a  condition  in  which  general  anaesthesia  is  imiversally  recognized  to  be 
extremely  perilous.  The  syncope  of  nervous  women,  the  tendency  to  faint  at 
the  sight  of  blood  or  pain,  and  even  a  history  of  habitual  syncope  from  slight 
causes  are  not,  when  unaccompanied  by  other  evidences  of  cardiac  or  vascular 
disease,  of  great  prognostic  importance  as  far  as  concerns  anaesthesia;  and  this 
because  they  are  rather  the  expression  of  an  tmduly  impressionable  sensorium 
than  of  a  morbid  vasomotor  apparatus,  and  it  is  just  the  office  of  anaesthesia  to 
abolish  the  sensorial  impressionability,  and  thereby  the  dangers  from  this  source 
are  ipso  facto  eliminated. 

A  much  more  miportant  consideration  is  calcareous  degeneration  of  the 
arteries,  whereby  they  lose  their  ability  to  adapt  their  calibre  to  the  varying 
demands  of  their  blood  content. 

(b)  Renal  Diseases.— Standing  m  an  intimate  and  sometimes  causal  relation 
to  the  affections  of  the  heart  and  blood-vessels  are  diseases  of  the  kidneys,  and, 
in  connection  with  the  prognosis  of  anesthesia,  these  must  be  considered  in 
their  reciprocal  relation;  i.e.,  both  the  effect  of  kichiey  disease  upon  the  cardio- 
vascular system  during  the  comparatively  brief  period  of  surgical  anaesthesia, 
and,  per  contra,  the  effects  of  anaesthetic  drugs  upon  the  diseased  kidneys.    It  is 


7S6  AJVIERICAN  PRACTICE   OF   SITiGERY. 

lor  lack  of  examination  of  this  subject  from  these  two  points  of  view  that  we  find 
such  divergent  and  conflicting  opuiions  with  regard  to  the  relative  safety  of  ether, 
chloroform,  and  other  anaesthetic  drugs. 

In  considering  the  effect  of  chronic  kidney  disease  upon  the  immediate  prog- 
nosis of  anesthesia,  i.e.,  upon  the  liabilitj-  of  the  patient  to  sudden  death  during 
or  shorth'  after  the  operation,  we  observe  that  the  modus  nocendi  of  chronic  kid- 
ney disease  is  not  through  defective  elimination  of  the  ordinary  urinar};-  toxins, 
for  even  total  suppression  of  renal  function  may  contuiue  some  hours  or  days 
without  fatally  compromising  the  life  of  the  individual ;  nor  yet  in  the  defective 
elimmation  by  way  of  the  kidneys  of  the  ansesthetic  which  is  being  administered, 
as  we  have  abimdant  experimental  proof  that  a  large  quota  of  its  elimination  is 
through  other  channels  (hmgs,  stomach) ;  but  rather  through  the  direct  effects 
of  chronic  nephritis  upon  the  cardiac  muscle  and  upon  the  walls  and  the  vaso- 
motor apparatus  of  the  arteries.  The  well-known  chronic  exaltation  of  blood 
pressure  fatigues  the  hj'pertrophied  and  diseased  heart,  there  is  no  reserve  fund 
of  cardiac  strength  to  draw  upon,  and  the  adaptive  function  of  the  vasomotor 
apparatus  is  chronically  inoperative;  hence  sudden  death  under  either  chloro- 
form or  ether. 

Viewed  from  the  opposite  standpoint,  we  must  consider  the  anesthetic  m 
the  line  of  an  irritant  drug,  similar  to  tm-pentine  or  cantharides  in  its  effect  upon 
the  diseased  kidney.  When  proper  weight  is  given  to  this  aspect  of  the  case,  it 
is  my  opinion  that  the  dogmatic  claims  regarding  the  superior  safety  of  ether 
over  chlorofrom  must  be  revised.  Ether  may  yield  fewer  cases  of  sudden  death 
during  or  shortly  after  ansesthesia,  but  in  the  subjects  of  cardiac,  vascular,  and 
renal  diseases  it  is  probably  answerable  for  a  considerable  proportion  of  those 
melancholy  cases  where  we  are  told  that  "the  operation  was  successful,  but  the 
patient  died." 

(c)  Diseases  of  the  Respiratory  Organs. — Concerniug  the  relation  of  diseases  of 
the  respiratory  organs  to  the  prognosis  of  surgical  anaesthesia,  we  may  be  more 
brief,  and  we  maj'  summarize  the  situation  by  saying  that  in  conditions  of  sub- 
acute and  chronic  inflammation  of  these  organs,  the  irritant  effect  of  anaesthetic 
drugs  administered  by  inlialation  must  be  accorded  a  considerable  prognostic 
weight.*  InsufHation  pnemnonias  are  easih'  induced  and  add  largely  to  the 
peril  of  anaesthetization,  especially  when  there  is  vomiting  on  the  operating  table. 
Particularly  dangerous  in  this  regard  is  the  putrid  and  fecal  vomit  of  obstruction 
to  the  alimentary'  canal,  whether  acute  or  chronic. 

2.  What  are  the  Morbid  Conditions  which  Especially  Enhance  the  Dangers 
of  Surgical  Operations  "  per  se  "  ? — It  will  be  seen  that  when  we  have  disposed 
of  those  affections  in  which  the  dangers  are  chiefly  from  the  ana?sthetic,  we  have 

*  In  the  presence  of  latent  bronchial  and  pulmonary  inflammations,  the  possible  advantages 
of  the  administration  of  ether  or  chloroform  by  the  rectum  might  merit  consideration,  and  so 
likewise  the  merits  of  "spinal  anaesthesia"  from  subdural  injections. 


GENERAL  SURGICAL  PROGNOSIS.  787 

greatly  limited  the  scope  of  our  present  inquiry;  nevertheless,  it  will  behoove  us 
to  pass  briefly  in  review  the  diseases  of  the  various  organs,  with  particular  refer- 
ence to  their  effect  upon  the  prognosis  of  surgical  operations  per  se. 

(a)  Cardiac  and  Vascular  Diseases.— With  regard  to  the  affections  of  the  cir- 
culatory system,  it  may  be  said  that  valvular  heart  disease,  especially  if  under- 
compensated, has  a  great  effect  upon  the  nutrition  of  the  tissues,  and  interferes 
greatly  with  the  capacity  of  the  organism  to  protect  itself  against  microbial 
invasion.  On  the  other  hand,  once  the  operation  is  overpast,  the  rest  in  bed, 
which  is  demanded  by  the  after-care  of  many  surgical  procedures,  may  act  most 
favorably  upon  a  cardiac  lesion.  Endarteritis  is  of  prognostic  importance,  in 
that  it  compromises  seriously  the  nutrition  of  the  tissues.  Its  influence  is  most 
markedly  unfavorable  in  the  treatment  of  gangrene  and  aneurism.  The  pres- 
ence of  phlebitis  is  of  great  moment,  even  if  it  does  not  affect  directly  the  part 
to  be  operated  upon,  because  it  involves  a  possibility  of  extensive  thrombosis, 
embolism,  and,  in  the  presence  of  sepsis,  of  pyaemia. 

.Marked  hereditary  hemophilia  raises  even  the  most  trifling  operations  to  a 
rank  of  extreme  peril. 

(b)  Renal  Diseases. — Few  surgeons  will  face  with  any  satisfaction  the  neces- 
sity for  operating  upon  parts  oedematous  from  chronic  renal  disease;  and  this 
aside  from  the  dangers  connected  with  ana;sthesia,  on  account  of  the  extreme 
liability  of  these  oedematous  tissues  to  pyogenic  invasion.  One  weighty  cotm- 
ter-indication  to  kidney  operations  must  be  borne  in  mind,  viz.,  the  possibility 
of  the  existence  of  but  a  single  kidney  (once  in  twenty-four  hundred  cases, 
Morris). 

(c)  Diseases  of  the  Respiratory  Organs. — On  the  part  of  the  respiratory  or- 
gans, the  connection  between  surgical  tuberculosis  and  latent  pulmonary  phthisis 
is  a  prognostic  factor  of  considerable  moment.  This  is  emphasized  in  cases  of 
anal  fistula. 

Careful  consideration  must  be  given  to  the  functional  capacity  of  the  oppo- 
site side  in  all  operations  upon  the  dual  organs  of  the  body — kidneys,  testicles, 
ovaries,  special  sense  organs,  etc. ;  e.g.,  in  the  operation  of  thoracotomy  the  func- 
tional coefficient  of  the  opposite  half  of  the  chest  is  of  prime  importance. 

Pulmonary  embolism  is  an  imtoward  accident  occasionally  complicating  even 
aseptic  operations.  It  is  particularly  prone  to  follow  upon  pelvic  operations, 
especially  where  there  has  been  much  bruising  of  the  tissues  or  slight  septic 
invasion.  Either  of  these  two  factors  gives  occasion  to  extensive  coagulation 
in  the  pelvic  veins  and  sinuses,  and  the  coagula  may  become  detached  and  be 
swept  along  to  the  lungs  in  overwhelming  masses.  They  may  even  prove  in- 
stantly fatal  by  blocking  the  right  side  of  the  heart. 

Fat  embolism  is  most  conspicuously  met  with  in  the  lungs,  and  gives  rise  to 
a  distressing  dyspnoea,  lastmg  until  such  time  as  the  heart  may  be  able  to  force 
through  the  pulmonary  capillaries  the  embolic  droplets  of  oil.     Fat  embolism 


788  AMERICAN  PRACTICE   OF  SURGERY. 

has  been  noted  with  relatively  great  frequency  in  the  insane,  as  a  sequel  to  mul- 
tiple contusions.  It  is  not  uncommon  after  extensive  omental  resections,  but  is 
most  frequently  noted  alter  fractures  of  the  shaft  of  the  long  bones.  The  out- 
come of  a  case  of  fat  embolism  is  chiefly  dependent  upon  two  factors — the 
amount  of  fat  within  the  blood-vessels  and  the  reseiwe  power  of  the  heart. 

(d)  Nervous  Diseases. — The  degenerative  diseases  of  the  nerv^ous  system  have 
not  much  effect  upon  surgical  prognosis,  except  those  involving  the  anterior 
ganglia  of  the  spinal  nerve  roots  and  transverse  lesions  of  the  spinal  cord.  In 
these  the  nutrition  of  the  parts  deriving  their  innervation  from  cord  segments 
at  or  below  the  seat  of  the  lesion  is  more  or  less  compromised.  Anterior  polio- 
myelitis, locomotor  ataxia,  disseminated  spmal  sclerosis,  and  paralysis  agitans 
do  not  of  themselves  seriously  impair  the  outcome  of  such  surgical  treatment  as 
may  be  demanded. 

Insanity,  idiocy,  and  epilepsy  do  not  greatly  affect  the  prognosis  of  sm-gical 
treatment.  As  Mayo  *  tells  us,  the  insane  are  entitled  to  just  the  same  surgical 
treatment  as  the  sane — no  more,  no  less.  The  relative  frequency  of  fat  embo- 
lism m  the  insane  has  been  noted  above. 

With  regard  to  the  reciprocal  effect  of  surgical  operations  upon  the  cerebral 
or  mental  lesion,  there  is  little  that  can  be  stated  definitely.  Some  few  cases 
have  been  brought  forward  by  Italian  sm-geons  to  vindicate  a  traumatic  origin 
for  insanity,  alleging  that  the  neurosis  was  caused  by  a  variety  of  surgical  opera- 
tions; but  when  we  examine  the  cases  reported,  we  find  that  all  the  patients 
were  strongly  predisposed  neuropathic  subjects,  with  unfavorable  environment, 
and  that  the  operations  either  were  upon  the  genital  organs,  or  else  occasioned 
some  bodily  disfigurement  which  gave  the  patient  great  annoyance.  Yet  just 
these  conditions  might  evoke  the  neurosis  in  others,  and  the  cautious  surgeon 
might  do  well  to  bear  this  possibility  m  mind  if  called  upon  to  operate  in  certain 
predisposed  individuals.  The  effects  of  surgical  operation  upon  the  established 
neurosis  are  extremely  problematical,  and,  while  ernes  have  followed  sm-gical 
relief  of  chronic  peripheral  irritants  (pelvic  and  abdominal  tumors,  operations 
upon  the  male  and  female  genitalia),  yet,  as  Mayo  advises,  the  criterion  is  not 
the  probable  effect  upon  the  mental,  but  rather  that  upon  the  general  somatic 
condition. 

In  considering  surgical  prognosis  with  reference  to  the  affections  of  the  ner- 
vous system,  we  must  take  account  of  the  subject  of  shock.  "We  have  already 
discussed  this  matter  with  reference  to  the  administration  of  the  anjesthetic; 
we  must  now  add  a  word  with  regard  to  the  advisability  of  operative  interven- 
tion per  se.  As  we  have  already  seen,  shock  manifests  itself  as  a  paresis  of  the 
vasomotor  system.  The  chief  danger  is  sinking  of  the  blood  pressure,  owing,  as 
we  have  said,  to  acute  hemorrhage,  to  cardiac  failm-e,  or  to  vasomotor  paresis. 
Tlie  extremely  bad  prognosis  in  operations  upon  patients  in  shock  is  hardly  due 
*  Mayo:  Med.  Record,  1901,  vol.  60,  p.  173. 


GENERAL  SURGICAL  PROGNOSIS.  789 

to  the  additional  hemorrhage,  because  with  modern  methods  of  htemostasis  this 
can,  with  sufficient  care,  be  kept  within  very  smaH  limits;  nor  is  it  due  to  car- 
diac weakness  strictiori  sensu,  because  we  may  be  dealing  with  a  heart  that  is 
without  valvular  lesion,  without  toxic  myocardial  degeneration,  and  that  may 
not  have  been  fatigued  by  over-exactions  of  work.  Aside,  then,  from  the  ques- 
tion of  supporting  the  anesthetic,  which  we  have  already  discussed  elsewhere, 
inasmuch  as  we  can  put  aside  both  additional  hemorrhage  and  cardiac  insuffi- 
ciency, in  the  stricter  sense  of  that  term,  it  follows  that  the  problem  of  prognosis 
in  conditions  of  shock  hinges  upon  the  ability  of  the  vasomotor  system  to  with- 
stand the  additional  irritation  incident  strictly  to  the  further  siu-gical  manipula- 
tions, without  having  the  vasomotor  paresis  deepen  to  complete  vasomotor 
paralysis,  which  is  death.  For  this  reason  full  ether  anesthesia  will  be  safer  than 
semi-angesthesia,  especially  than  semi-ansesthesia  with  chloroform.  It  is  the 
common  consensus  of  railroad  surgeons,  who  see  the  most  cases  of  acute  shock, 
that  if  hemorrhage  has  been  arrested,  and  further  irritation  of  the  sensorium  has 
been  removed  by  keeping  the  patient  at  rest  (with  morphine  if  necessary)  and 
protected  from  further  loss  of  bodily  heat,  the  prognosis  is  much  improved  by 
waiting  for  at  least  a  partial  subsidence  of  shock  before  undertaking  any  con- 
siderable surgical  procedures. 

Neurasthenia  is  likewise  a  subject  which  demands  reciprocal  consideration. 
Of  this  question  the  first  phase  is  the  effect  of  neurasthenia  upon  the  outcome  of 
surgical  conditions ;  and  the  answer  is  that  the  effect  is  little  or  none,  excepting 
in  those  types  of  neurasthenia  which  interfere  with  the  general  bodil}^  nutrition. 

To  the  second  phase  of  this  question,  to  wit,  the  effect  of  surgery  upon  the 
neurasthenia,  it  is  very  difficult  to  give  a  satisfactory  answer.  If  the  surgical 
operation  removes  an  irritant  antedating  in  its  history  the  onset  of  the  neuras- 
thenia, and  one  which  may  be  deemed  to  be  the  cause  of  the  neurasthenic  condi- 
tion {e.g.,  chronic  appendicitis,  uterine  or  permeal  lacerations,  chronic  prosta- 
titis), a  good  effect  upon  the  neurasthenia  may  be  expected  from  the  operation. 
If  the  surgical  troubles  do  not  stand  m  a  causal  relation  to  the  neurasthenia,  the 
effect  of  operation  per  se  may  be  to  deepen,  rather  than  to  relieve,  the  neuras- 
thenia; yet  it  should  be  remembered  that  by  skilful  suggestion  on  the  part  of 
the  physician  he  may  array  the  powerful  impression  of  a  surgical  operation 
upon  the  imagination  of  a  suggestible  patient,  among  the  forces  working  for, 
rather  than  against,  recovery  from  the  neurasthenia.  It  is  in  so  far  as  they  in- 
duce in  the  subject  oftentimes  a  quasi-physiological  condition  of  neurasthenia, 
that  menstruation,  pregnancy,  and  the  menopause  may  affect  surgical  progno- 
sis. Too  frequently  repeated  pregnancy  and  too  prolonged  suckling  act  in  the 
same  way. 

Emotional  conditions  are  not  without  their  bearing,  as  is  seen  in  the  com- 
parative mortality  of  the  wounded  among  the  victors  and  among  the  vanquished  . 
on  the  battlefield. 


790  AMERICAN   PRACTICE   OF   SURGERY. 

The  effect  of  over-fatigue,  exliaustion,  exposure,  and  hunger  is  obviously 
unfavorable. 

(e)  Diseases  of  the  Alimentary  Tract. — A  condition  of  the  alimentary  tract 
most  unfavorable  to  surgical  prognosis  is  one  where,  owing  to  either  motor  or 
secretory  distui'bances,  that  condition  is  developed  which  has  been  crudely 
called  "stercorsemia,"  inasmuch  as  it  magnifies  the  inevitable  post-operative 
discomforts  and  disturbances  to  a  degree  which  may  become  very  serious ;  vom- 
iting, headache,  meteorism,  obstinate  constipation,  and  colic  are  bugbears  of 
the  abdominal  sm-geon,  and  have  a  direct  connection  with  intestinal  putrefaction 
and  absorption.  On  this  account  a  certain  degree  of  gravity  attends  all  opera- 
tions done  without  preliminary  evacuation  of  the  alimentarj^  canal;  and  this 
explains  in  considerable  measure  the  high  mortality  from  strangulated  hernia 
and  other  forms  of  mechanical  obstruction  of  the  intestines.  Mere  obstipation 
— that  is,  the  loading  of  the  bowel  with  large  masses  of  hardened  faeces — is  of 
less  unfavorable  moment  than  the  presence  within  the  intestines  of  a  much  less 
considerable  amount  of  fecal  material  in  a  softer  and  more  fluid  condition,  per- 
mitting the  more  ready  absorption  of  toxins  generated  by  intestinal  putrefaction. 

When  to  the  products  of  the  general  putrefaction  of  the  intestinal  contents 
are  added  the  specific  toxms  of  disease,  a  condition  which  is  conspicuously  pres- 
ent in  typhoid  fever,  the  gravity  of  the  prognosis,  when  operative  intervention 
becomes  imperative,  is  undoubtedly  greatly  increased.  Yet  surgery  has  recently 
been  invoked  with  considerable  frequency  for  the  repair  of  intestinal  perfora- 
tions in  typhoid  fever,  and  with  a  success  which  has  been  on  the  whole  gratify- 
ing. Gesselewitsch  and  Wanach  *  collected  reports  of  63  operations  with  11 
recoveries.    The  most  recent  reports  show  a  slightl}''  better  percentage. 

In  considering  lesions  of  the  liver  in  their  relation  to  surgical  prognosis,  it  is 
important  to  bear  in  mind  the  difficulty  attending  upon  a  proper  hfemostasis  in 
cases  of  cholsemia,  on  accoimt  of  the  deficient  coagulability  of  the  blood.  So 
considerable  is  the  danger  of  hemorrhage  from  this  cause  that,  where  it  is  pos- 
sible, operations  not  of  the  greatest  urgency  should  be  postponed  until  after  the 
subsidence  of  the  cholsemia,  or  until  the  exliibition  of  calcium  chloride  or  other 
suitable  drugs  shall  have  demonstrated  a  fairly  satisfactory  rapidity  of  coagula- 
tion upon  suitable  tests. 

In  obstructions  of  the  common  duct  the  likelUiood  of  the  supervention  of 
acute  hemorrhagic  pancreatitis  and  fat  necrosis  is  an  important  prognostic  ele- 
ment. In  estimating  the  prognosis  in  any  disease  of  the  chylopoietic  system, 
the  determination  of  the  stage,  in  what  may  be  called  the  "biliary  sequence," 
in  which  the  patient  under  consideration  may  find  himself,  is  an  important  prog- 
nostic moment;  that  is,  his  chances,  if  he  be  suffering  from  cholecystitis,  of 
having  this  develop  a  cholelithiasis,  and  this  in  turn  an  obstructive  cholangitis, 

*  Quoted  in  von  Bergmann  and  Bull's  "System  of  Practical  Surgerj',"  vol.  iv.,  p.  319,  New 
York,  1904. 


GENERAL  SUEGICAL  PROGNOSIS.  791 

whence  perihepatitis,  pancreatitis,  and,  eventually,  pancreatic  diabetes.  In 
questions  of  this  kind  the  familj'  history  acquires  great  prognostic  importance. 
In  a  family  in  which  there  may  have  been  several  diabetics,  the  earlier  stages 
in  the  "biliary  sequence"  have  a  less  favorable  prognosis  than  when  occurrmg 
in  families  not  so  predisposed. 

(/)  Diseases  of  the  Ductless  Glands. — The  danger  in  operating  upon  those  who 
are  the  subjects  of  Graves'  disease  seems  to  come  principally  from  the  side  of  the 
heart.  Aside  from  thyroidectomy  and  other  operations  directed  specifically 
toward  the  cure  of  the  disease  itself,  the  special  prognosis  of  which  operations 
will  be  discussed  elsewhere  in  this  work,  the  warm  extremities  of  sufferers  from 
Graves'  disease,  due  as  they  are  to  wide  vascular  dilatation  and  a  rapidly  flowing 
blood  stream,  are  an  indication  of  conditions  favorable  for  the  repair  of  the 
tissues,  if  only  the  heart  be  able  to  sustain  the  depression  due  to  anaesthesia  and 
the  shock  incident  to  operation. 

In  myxoedema,  on  the  other  hand,  while  the  danger  from  the  side  of  the  heart 
is  less,  the  condition  of  the  tissues  is  less  favorable  for  the  repair  of  travuna  and 
for  resistance  to  microbial  invasion. 

(g)  Diseases  of  the  Blood. — In  considering  the  bearing  of  the  condition  of  the 
blood  upon  surgical  prognosis,  we  touch  upon  a  theme  that  will  be  handled  more 
fully  elsewhere  in  this  work  under  the  head  of  surgical  hsematology  (see  page 
555).  The  simple  question  of  hfemoglobin  percentage  has  an  important  bear- 
ing upon  prognosis,  especially  with  regard  to  cases  which  it  is  proposed  to  sub- 
mit to  operation.  For  weighty  observations  on  this  point  we  are  specially 
indebted  to  von  Mikulicz.  He  has  studied  m  patients,  in  whom  conditions 
were  otherwise  favorable,  but  who  had  suffered  considerable  loss  of  blood  by 
acute  hemorrhage,  the  length  of  time  necessary  for  the  restoration  of  the  blood 
mass,  and  he  finds  a  period  of  from  two  to  five  days  necessary  for  its  restora- 
tion where  less  than  one  per  cent  of  the  blood  in  the  body  has  been  lost;  while, 
with  a  loss  of  between  three  and  four  per  cent  of  the  blood  m  the  body,  from 
fourteen  to  thirty  days  are  required  to  make  good  the  loss  of  blood.  These  are 
more  or  less  fixed  data  which  will  govern  the  prognosis  for  operations  upon 
otherwise  normal  healthy  individuals.  A  pre-existmg  ansemia,  indicating  a 
deficient  hematopoietic  function,  will  add  greatly  to  the  periods  of  time  neces- 
sary for  blood  regeneration;  and,  according  to  von  Mikulicz,  a  hsemoglobm  per- 
centage below  30  is  a  positive  coimter-indication  to  operation,  until  medical 
treatment  shall  have  enriched  the  blood  to  at  least  this  critical  minimum. 

Aside  from  the  questions  of  blood  mass  and  hajmoglobin  percentage,  the  new 
science  of  htematocytology  has  brought  for  our  use  many  facts  bearing  directly 
upon  general  si_u-gical  prognosis.    They  can  be  but  briefly  alluded  to  here. 

The  red-cell  coimt  is  of  great  prognostic  importance,  and  a  diminution  to 
anything  below  3,500,000  must  be  considered  to  compromise  the  prognosis  most 
seriously  in  all  cases  not  due  to  acute  hemorrhage. 


792  AMERICAN  PRACTICE  OF  SURGERY. 

Leaving  for  proper  treatment  elsewhere  the  interpretation  of  differential 
blood  counts,  we  may  mention  here,  because  of  its  direct  bearing  upon  our  sub- 
ject, the  salient  points  in  which  leucocytosis  indicates  the  prognosis  in  surgical 
cases,  and  especially  in  pyogenic  processes. 

1.  The  degree  of  leucocytosis  is  independent  of  the  amount  of  pus. 

2.  An  increasing  leucocytosis  points  to  a  spreading  pyogenic  process. 

3.  The  absence  of  leucocytosis  in  the  undoubted  presence  of  pus  indicates : 
(a)  That  the  pus  has  become  sterile,  owing  to  the  death  of  the  invading  bac- 
teria. 

(/S)  That  the  pus  has  been  thoroughly  walled  off  by  granulation  tissue. 

(r)  That  the  case  is  of  the  "fulminating  type,"  and  of  such  virulent  onset  that 
a  prophylactic  chemotaxis  has  not  established  itself. 

The  slow  coagulation  of  the  blood  in  cholgemia  and  the  prognostic  importance 
of  hereditary  haemophilia  have  already  been  alluded  to. 

{h)  Acute  Infectious  Diseases. — The  presence  of  acute  infectious  disease  will 
undoubtedly  counter-indicate  any  but  the  most  urgent  surgery.  Particular 
stress  should  be  laid  upon  measles,  on  account  of  the  increased  danger  in  antes- 
thesia,  owing  to  the  accompanying  bronchitis;  scarlet  fever,  on  account  of  its 
intimate  relation  with  erysipelas ;  smallpox  and  even  cliickenpox,  on  account  of 
the  pustular  character  of  the  eruption;  and  diphtheria,  on  account  of  the  ex- 
treme probability  of  local  wound  infection.  In  addition  to  these,  pertussis,  be- 
sides the  danger  to  the  lungs  from  the  anaesthetic,  is  particularly  dangerous  in 
abdominal  surgery,  on  account  of  the  impossibility  of  securing  rest  to  the  ab- 
dominal walls.  Grippe,  furthermore,  is  a  great  foe  to  the  surgeon,  as  it  renders 
its  subjects  particularly  vulnerable  to  the  attack  of  pyogenic  germs.  Some 
striking  examples  of  this  have  been  observed  and  reported  by  Bennett.* 

(i)  Constitutional  Diseases. — The  diseases  of  metabolism,  so-called  constitu- 
tional diseases,  which  particularly  concern  the  surgeon,  are  four — rickets,  syph- 
ilis, gout,  and  diabetes.  The  relation  of  rickets  to  general  prognosis  is  simply 
that  of  malnutrition  in  general,  the  prognosis  of  the  specific  bone  lesions  of  rick- 
ets being  properly  a  part  of  special  prognosis.  When  bodily  nutrition  is  other- 
wise good,  wounds,  so  far  as  my  observation  goes,  heal  as  well  in  rickety  sub- 
jects as  in  others. 

Syphilis,  if  recognized  and  if  met  by  suitable  internal  medication,  need  not 
deter  the  surgeon  from  such  operative  measures  as  may  be  deemed  advisable; 
if  unrecognized  and  untreated,  it  may  hinder  seriously  the  powers  of  repair,  and 
operation  wounds  may  prove  to  be  a  locus  minoris  resistentice,  upon  which  a 
gummatous  process  may  become  engrafted  with  disastrous  results.  The  con- 
sideration of  the  outcome  of  the  surgical  treatment  of  specific  syphilitic  lesions 
(gummata,  etc.)  lies  in  the  field  of  special  rather  than  in  that  of  general  prognosis. 

*  W.  H.  Bennett:  "Brief  Notes  of  Some  Cases  of  Pyjemia  and  Suppuration,  Apparently 
Due  to  the  Prevailing  Epidemic  of  Influenza,"  Lancet,  Lond.,  1890,  i.,  p.  200. 


GENERAL  SURGICAL  PROGNOSIS.      .  793 

Gout  has  its  chief  surgical  interest  in  two  points:  first,  the  vulnerability  of 
its  subjects  in  presence  of  microbial  invasion;  and,  secondly,  the  probable  exist- 
ence of  gouty  nephritis,  not  distinguishable  in  its  symptomatology  nor  in  its 
prognostic  importance  from  other  forms  of  chronic  nephritis. 

Of  very  special  interest  to  the  surgeon,  on  the  other  hand,  is  diabetes.  The 
disastrous  effects  of  surgical  operations  upon  diabetics  have  led  some  to  the  ab- 
solute proscription  of  all  operations  in  the  presence  of  this  disease.  This  extreme 
position  we  cannot,  however,  maintain,  and  it  behooves  us  to  consider  this  ques- 
tion, as  we  have  several  others  that  we  have  met,  in  its  reciprocal  relations: 
that  is,  first.  What  is  the  effect  of  diabetes  upon  surgical  procedures  and  condi- 
tions? and,  secondly.  What  is  the  effect  of  surgical  procedures  upon  the  diabetes? 

The  first  question  ranges  itself  in  a  class  strictly  parallel  with  other  chronic 
dyscrasige,  such  as  gout,  syphilis,  or  chronic  alcoholism;  and  acute  dyscrasise, 
such  as  scurvy  and  the  toxaemias  of  acute  disease,  in  that  diabetes  causes  a  very 
greatly  increased  vulnerability  of  the  tissues  and  renders  them  particularly  sus- 
ceptible to  the  invasion  and  development  of  pyogenic  germs.  Thus  furuncles, 
carbuncles,  and  other  phlegmonous  and  gangrenous  processes  will  follow  upon 
slight  infection.  Operations  especially  dangerous  in  diabetics  are  those,  like 
circumcision  for  diabetic  balano-posthitis,  where  rigid  asepsis  is  difficult  or  im- 
possible. The  low  resistance  of  the  tissues  in  diabetics  is,  furthermore,  influ- 
enced by  the  chronic  endarteritis  which  this  disease  induces. 

The  other  phase  of  this  question,  viz.,  the  effect  of  surgical  procedures  upon 
the  diabetic  process,  bears  a  still  more  forbidding  aspect,  and  diabetic  coma 
looms  as  a  dreadful  spectre  before  the  surgeon  called  upon  to  operate  upon  dia- 
betic patients,  and  the  difficulty  is  to  find  a  proper  criterion  by  which  to  judge 
of  those  in  whom  coma  is  likely  to  develop.  There  is  no  one  factor  that  will 
serve  to  guide  us,  and  our  chief  dependence  must  be  in  the  summation  of  the 
different  evidences  of  grave  diabetes. 

Of  these,  the  age  of  the  patient  has  considerable  weight;  the  more  advanced 
age  being  in  this  case  more  favorable  as  regards  prognosis,  inasmuch  as  "dia- 
betes gravior"  appears  more  frequently  in  the  young,  and  "diabetes  mitior" 
more  frequently  in  the  aged.  The  absence  of  the  patellar  reflex,  though  it  is 
not  conclusive  evidence  of  a  grave  diabetic  condition,  yet  must  be  considered  an 
unfavorable  symptom.  The  coexistence  of  albuminuria  and  glycosuria,  and 
more  particularly  the  substitution  of  albuminuria  for  a  pre-existing  glycosuria, 
are  of  great  importance.  Cachexia  and  emaciation  do  not  seem  to  have  as  much 
weight  as  might  be  supposed,  apparently  well-nourished  individuals  of  vigorous 
appearance  succumbing  as  rapidly  as  others.  Sufficient  recorded  observations 
are  not  available  to  enable  us  to  judge  as  to  the  prognostic  value  of  heredity  in 
diabetes— that  is,  whether  a  diabetic  patient,  a  member  of  a  diabetic  family,  is 
more  liable  to  post-operative  accidents  than  is,  cceteris  paribus,  a  diabetic  patient 
not  so  related;  nor  do  recorded  observations  throw  any  light  as  to  the  liability 


794  AMERICAN  PRACTICE  OF  SURGERY. 

to  post-operative  accidents  of  diabetics  whose  diabetes  comes  as  the  concluding 
member  of  the  "biliary  sequence,"  as  compared  with  those  whose  diabetes  has 
had  no  antecedent  cholelithiasis,  biliary  stasis,  and  chronic  pancreatitis.  Both 
of  these  points,  however,  merit  consideration. 

When  we  consider  the  characteristic  urinary  excreta  of  diabetics,  we  can 
dispose  of  the  polyuria  and  of  the  amoimt  of  sugar  as  not  in  themselves  con- 
clusive, though  their  behavior  under  appropriate  dietary  and  medicinal  treat- 
ment is  of  some  prognostic  weight. 

The  other  characteristic  excreta  are  acetone,  aceto-acetic  (diacetic)  acid,  and 
beta-oxybutyric  acid.  It  seems,  from  chemical  grounds,  reasonable  to  suppose 
that  beta-oxybutyric  acid  is  the  first  of  these  to  be  formed  in  cases  of  beginning 
diabetic  "acidosis,"  and  that,  when  the  disturbance  of  metabolism  is  not  too 
severe,  this  is  further  oxidized  to  aceto-acetic  acid,  and  then  to  acetone  and  car- 
bonic acid.  With  further  disturbance  of  metabolism,  the  oxidation  does  not 
proceed  beyond  the  stage  of  diacetic  acid,  which  accordingly  is  found  in  the 
urine;  while,  with  still  further  metabolic  disturbance,  beta-oxybutyric  acid  ap- 
pears in  that  secretion  unchanged.  Acetone,  diacetic  acid,  and  beta-oxybutyric 
acid  in  the  urine  are  of  successively  important  prognostic  significance  when  it  is 
proposed  to  attempt  surgery  upon  diabetic  subjects. 

The  appearance  of  aceto-acetic  acid  and  of  beta-oxybutyric  acid  in  the  urine 
(also  other  acids,  sethylidene  lactic  acid,  alpha-oxypropionic  acid,  and  transitory 
fatty  acids  found  in  the  urine  of  diabetics)  is  the  sign  of  beginning  acidosis,  and 
manifests  itself  by  an  increase  of  the  excretion  of  ammonium  in  the  urine,  in 
that  the  acids  which  appear  in  the  blood  are  combined  with  ammonium.*  A 
quantitative  estimate  of  ammonium  in  the  urine  might,  therefore,  be  of  prog- 
nostic value.  The  method  recently  suggested  by  Folin  f  is  not  too  elaborate  for 
clinical  use  in  an  important  case. 

The  simple  examination  of  cover-glass  preparations  of  the  blood  for  free  fat 
droplets  t  would  also  suggest  itself  as  a  reasonable  precaution.  Great  increase 
in  the  normal  fat  content  of  the  blood  (0.75-0.85  per  cent)  is  characteristic  of 
severe  diabetes,  in  which  amounts  varying  from  1.276  per  cent  to  11.7  per  cent 
have  been  encountered.  In  such  cases  fat  embolism  may  be  found  post  mortem, 
plugging  the  vessels  of  various  organs,  notably  the  brain,  the  lungs,  and  the 
kidneys;  and  this  fat  embolism  may  account  for  many  of  the  untoward  post- 
operative accidents  in  diabetes.  The  preliminary  dyspnoea  which  ushers  in  dia- 
betic coma  is  probably  due  to  this  cause. 

To  sum  up,  a  careful  surgeon,  before  undertaking  operation  upon  a  diabetic 
subject,  would  do  well  to  make  the  following  preliminary  investigations :  1,  The 

*  Leube:   "Medical  Diagnosis,"  New  York,  1904,  p.  828. 

t  O.  Folin:  Zeitschr.  f.  physiol.  Chem.,  vol.  xxxii.,  p.  575;  found  also  in  Simon's  "Clinical 
Diagnosis,"  Phila.,  1902. 

}  Simon:   Op.  cit.,  p.  56. 


GENERAL  SURGICAL  PROGNOSIS.  795 

age  of  the  patient;  2,  the  heredity;  3,  the  history  of  previous  bihary  trouble; 
4,  the  condition  of  the  patellar  reflex;  5,  an  examination  of  the  blood  for  excess 
of  free  fat;  6,  the  presence  of  albuminuria;  7,  the  behavior  of  the  polyuria  and 
the  glycosuria  vmder  appropriate  treatment;  8,  the  determination  of  acetone, 
diacetic  acid,  and  beta-oxybutyric  acid;  9,  if  any  one  of  these  three  substances 
is  found  in  the  urine,  a  determination  of  the  total  ammonium  excretion. 

(k)  Concomitant  Pyogenic  Disease. — Another  matter  calling  for  consideration 
before  undertaking  surgical  operations  is  the  possibility  of  the  existence  of  a 
latent  and  concealed  nidus  of  pyogenic  infection  outside  of  the  field  of  operation, 
as  such  a  smouldering  process  may  be  greatly  quickened  by  operative  manipu- 
lations even  at  some  distance  from  such  a  focus,  and  may  induce  septicaemia  or 
pyaemia,  in  spite  of  a  faultless  operative  technique.  Chronic  encysted  foci  of 
osteomyelitis,  and  chronic  but  quiescent  cholangitis,  are  particularly  liable  to 
take  on  such  imtoward  activity;  but  perhaps  the  most  conspicuous  case  of  all 
is  when  virulent  pelvic  inflammation  develops  after  a  simple  uterine  curettmg, 
done  in  the  presence  of  a  quiescent  pyosalpLnx. 

3.  Special  Disease  Conditions  Bearing  upon  General  Prognosis.— Inasmuch 
as  it  is  well  recognized  that  the  preliminary  stages  of  anaesthesia — what  with  the 
struggling  of  the  stage  of  excitement,  and  the  spastic  closure  of  the  lips  and 
glottis,  and  the  vomiting — are  often  attended  by  a  temporary  rise  in  the  blood 
pressure,  it  is  well  to  notice  in  this  connection  certain  conditions  already  alluded 
to  in  considering  the  prognostic  importance  of  parturition,  where  this  rise  of 
blood  pressure  might  occasion  rupture  or  harmful  distention  of  the  blood-ves- 
sels. The  principal  conditions  in  this  category  are  aneurisms,  varices,  and  some 
intracranial  affections.  In  the  operations  of  cataract  extraction  and  even  simple 
iridectomy,  the  possibility  of  collapse  of  the  ocular  globe  and  escape  of  the  vitre- 
ous humor  through  the  wound  must  be  borne  in  mind.  Struggling  of  the  patient 
during  preliminary  anaesthesia  may  greatly  affect  the  prognosis  in  the  case  of 
certain  thin-walled  abscesses  and  cysts,  which  may  burst  and  carry  their  infec- 
tious contents  into  the  great  serous  cavities. 

v.  Environment. 

Under  the  head  of  environment  we  must  consider  not  only  the  literal  mate- 
rial objects  surrounding  the  patient,  but  we  must  use  the  term  in  its  wider  sense, 
so  as  to  cover  the  relation  established  between  the  individual  and  external  ob- 
jects, so  that  we  may,  as  already  suggested,  include  in  our  study  of  environment 
his  occupation,  his  food,  the  climatic  conditions  under  which  he  lives,  his  ability 
to  create  about  himself  hygienic  conditions,  and  his  disposition  through  habit  or 
training  to  observe  the  laws  of  hygienic  living. 

Yet  first,  in  the  more  restricted  sense  of  the  word  "environment,"  we  should 
consider  such  questions  as  the  prognosis  in  emergency  or  field  surgery  as  com- 


796  AMERICAN  PRACTICE   OF  SURGERY. 

pared  with  the  prognosis  under  liospital  surromidings ;  evidently  manj^  cases  of 
good  prognosis  under  hospital  conditions  would  have  a  less  favorable  prognosis 
on  the  battle-field  or  in  the  railroad  wreck.  But,  on  the  other  hand,  even  a  well- 
appointed  hospital  is  not  without  its  own  proper  disadvantages ;  for  instance,  a 
succession  of  cases  of  tetanus  or  of  erysipelas  occurring  in  a  certain  operating- 
room  or  hospital  ward  may  most  unfavorably  affect  the  prognosis  in  a  whole 
group  of  cases.  Other  things  being  equal,  so  far  as  the  material  surroundings  of 
the  patient  are  concerned,  the  best  prognosis  should  obtain  in  the  private  homes 
of  reasonably  well-to-do  people. 

Under  this  head  of  environment  belongs  the  consideration  of  the  social  and 
economic  status  of  the  patient,  his  ability  to  secure  good  food,  sufficient  protec- 
tion, proper  attention  to  his  wants,  freedom  from  worry  and  excitement — all  of 
which  may  cast  the  balance  favorably  or  unfavorably  as  regards  recovery,  and 
should,  in  not  a  few  instances,  determine  for  us  the  therapeutic  measures  to  be 
adopted.  Some  social  circumstances  justify  risks  which  other  social  circum- 
stances would  not  justify.  To  a  typesetter  or  a  pianist  the  loss  of  a  finger  joint 
would  mean  much  more  than  to  a  laborer;  and  for  a  poor  man  with  a  large 
family,  the  amputation  of  a  leg,  with  prompt  recovery,  might  be  a  far  less  seri- 
ous disaster  than  conservation  of  the  limb  after  months  of  hospitalization  and 
invalidism.  An  artificial  anus  or  a  permanent  gastric  or  urinary  fistula  are  hor- 
rible afflictions  where  cleanliness  cannot  be  counted  upon,  yet  they  may  afford 
months  or  years  of  comparatively  comfortable  living  to  those  who  can  be  prop- 
erly waited  upon  or  who  imderstand  and  habitually  practise  a  rational  personal 
hygiene.  In  female  patients  of  means  and  leisure,  pelvic  operations  may  be  in- 
definitely postponed,  when  rest  and  luxury  are  available  to  mitigate  surgical 
conditions  which  the  harder  life  of  less  prosperous  patients  would  make  un- 
bearable. 

The  personal  habits  of  the  patient  bear  most  decidedly  on  prognosis.  Sloth, 
gormandizing,  sexual  excesses  and  perversions,  inordinate  use  of  tobacco,  or 
other  stimulants  or  narcotics  are  prognostic  factors  of  great  weight.  Chronic 
alcoholism  is  perhaps  the  one  factor  most  generally  inimical  to  the  recovery  of 
surgical  patients  in  hospital  practice,  on  account  of  the  depraved  nutrition  of 
the  tissues  and  their  consequent  low  powers  of  resistance;  on  account  of  the  dis- 
eased liver,  kidneys,  and  blood-vessels  of  chronic  inebriates;  on  account  of  the 
over-stimulated  and  unresponsive  heart ;  and,  lastly,  on  account  of  the  liability 
to  delirium  tremens.  A  reliable  criterion  by  which  to  gauge  the  likelihood  of 
the  supervention  of  delirium  tremens  is  nearly  as  difficult  to  establish  as  is  a 
criterion  for  estimating  the  probability  of  diabetic  coma,  yet  I  have  endeavored 
to  assemble  below  the  points  which  would  seem  to  me  to  indicate  special  liabil- 
ity to  this  accident.    They  are : 

1.  The  age  of  the  patient,  or,  rather,  the  length  of  time  that  he  has  indulged 
the  drinking  habit. 


GENERAL  SURGICAL  PROGNOSIS.  797 

2.  The  occupation  of  the  patient.  This  is  parallel  to  the  "moral  risk"  of  the 
life-insurance  actuaries,  as  it  gauges  more  or  less  accurately  the  drinking  habits 
of  the  patient.  Proscribed  occupations  are  liquor-dealers,  wholesale  or  retail; 
drummers  for  such;  bartenders  and  other  employees  in  breweries,  distilleries, 
and  saloons;  hotel-keepers,  etc. 

3.  The  acknowledged  drinking  habits  of  the  patient.  Habitual  drinkers  who 
are  never  "drunk"  are  worse  subjects  than  are  periodical  drunkards,  save  when 
the  latter  present  themselves  for  surgical  treatment  at  the  close  of  a  severe  spree. 

4.  Loss  of  the  knee-jerk  is  observed  in  the  quiet  stage  of  alcoholism.  It  in- 
dicates a  considerable  degree  of  toxaemia  and  is  of  unfavorable  prognostic  sig- 
nificance. An  exaggerated  knee-jerk  is  seen  in  the  stage  of  excitement,  and,  if 
accompanied  by  alcoholic  tremor,  it  is  still  more  unfavorable  than  is  loss  of  the 
knee-jerk. 

5.  The  well-known  tremor  of  the  hands  is  most  unfavorable. 

6.  Alcoholic  gastritis  indicated  by  morning  vomiting,  anorexia,  and  inability 
to  retain  or  digest  food. 

7.  Starvation  and  exposure. 

8.  The  combination  of  alcoholism  with  any  demonstrable  organic  lesion  of 
the  liver,  lungs,  or  the  kidneys;  or  any  constitutional  disease,  such  as  antemia, 
gout,  or  diabetes;  or  any  acute  infectious  disease,  such  as  malaria  or  influenza. 

A  final  factor  to  be  considered  is  climate.  A  tropical  climate  is  depressing  to 
those  not  habituated  to  it  and  to  those  who  have  not  learned  or  will  not  practise 
a  reasonable  tropical  hygiene.  In  such  subjects  surgical  operations  have  an 
additional  element  of  peril,  which  can  be  greatly  reduced  by  removal  for  opera- 
tion to  the  temperate  zones.  The  prognosis  of  many  surgical  diseases  of  the 
upper  respiratory  passages  and  of  the  thorax,  and  of  many  surgical  affections  of 
the  urinary  organs,  is  most  favorably  influenced  by  a  dry  and  equable  climate. 
The  effect  of  sunshine  and  open-air  life  is  no  less  marked  upon  surgical  tubercu- 
losis than  it  is  upon  those  tuberculous  affections  of  the  lungs  and  other  mternal 
organs  which  come  more  especially  xmder  the  care  of  the  physician. 


INDEX 


Abdomen,  inspection  of,  for  diagnosis,  514 
Abdominal    aorta,    diagnostic    significance  of 
pulsation  in,  531 

cavity,  surgery  of,  62 
Abscess,  definition  of  the  term,  121 

formation  of,  121,  416 
Abscesses,  128 

acute,  254 

burrowing,  14] 

cold  or  chronic,  141,  255 

congestive,  141 

embolic,  128,  129 

external  discharge  of  dead  material  from, 
233 

healing  of,  103 

metastatic,  129 

miliary,  129 
Absorbable  sutures,  728 

Acetone  in  the  urine  of  diabetics  an  unfavor- 
able prognostic  sign,  794 
Acidosis  in  diabetic  patients,  794 
Acromegaly,  x-Ta,y  features  of,  685 
Actinomycosis  leads  to  ulceration,  227 
Actual  cautery  as  a  sterilizing  agent,  710 
Adami,  J.  G.;  Classification  of  tumors,  297 
Adeno-carcinoma,  346,  356 

primary,  in  mice,  390 
Adeno-fibroma,  304,  346 
Adenoma,  345 

alveolar,  345 

its  relations  to  glandular  hyperplasia,  349 

its  transition  to  malignancy,  350 

malignum  or  carcinomatosura,  350 

of  breast,  346 

of  kidney,  346 

of  prostate,  348 

of  suprarenal  capsule,  347 

of  testis,  348 

of  thyroid,  347 

of  uterus,  349 

papuliferous,  345 

tubular,  345 
Adeno-sarcoma,  or  cystadeno-sarcoma,  348 
Adhesive  plaster,  736 

after   abdominal  operations   and   for  ab- 
dominal support,  737 

in  closure  of  wounds,  738 
Adrenalin  in  treatment  of  shock,  494,  495 


Age  as  influencing  diagnosis,  507 

influence   of,   upon   prognosis  in  surgical 
diseases,  772 
Aged,  operations  upon  the,  776 
Agglutination  thrombi,  85 
Agglutinin  and  its  action,  417 
Agnew,  D.  Hayes,  19 
Air  as  a  source  of  infection,  698 
Albuminuria,  568 

surgical  importance  of,  when  due  to  pres- 
ence of  blood  in  the  urine,  569 
Alcohol  as  an  accessory  hand  disinfectant,  707 
Alexin  action  of,  418 

Alimentary  tract,   disorders  of,  in  tlieir  rela- 
tion to  surgical  prognosis,  790 
American  practice  of  surgery,  characteristics 

of,  39 
Ammonium  excretion,  total,  determination  of, 

in  diabetic  patients,  795 
Amputation  neuroma,  289 

of  limbs,  46 
Amyloid,  194,  195 

appearance  of  organs  affected  by,  196 
diseases  in  which  it  is  frequently  found,  195 
experimentally  produced,  195 
views  of  von  Recklinghausen  and  Czerny 
in  regard  to  sources  of,  195 
Amyloid  transformation,  a  result  of  prolonged 

suppuration,  255 
Anaemia,  234,  238 

circumscribed,  239 
collateral,  239 

pernicious,  blood-counts  in,  241 
from  hemorrhage,  245 
primary,  240,  241 
secondary,  240,  244 
Anaemic  necrosis  or  infarction,  239 
Anaesthesia,  63 

first  operation  under,  63 
its  relation  to  surgical  shock,  479 
to  facilitate  diagnosis,  553 
moral,  489 

used  for  diagnostic  examination,  553 
Anaesthetics,  administration  of— circumstances 
under  which  it  is   especially  dangerous. 
784 
irritant  effects  of,  upon  certain  diseases, 
786 


800 


INDEX. 


Anasarca,  definition  of,  236 

Anatomical  appearances  as  diagnostic  factors, 

513 
Aneurism,  Hunter's  principles  of  treatment  of, 
39 

operations  for,  by  Wright  Post,  40 

traumatic,  after  organization  of  clot,  2SS 
Angioma,  319 

arteriale  racemosum,  321 

fissural,  321 

neuropathic,  321 

senile,  321 

simple  hj'pertrophic,  320 

Thoma's  views  of  its  etiologj',  322 

traumatism  a  cause  of,  321 
Angio-sarcoma,  320,  333,  338,  340,  344 

endothelial,  323,  340 

perithelial,  323,  340 

plexiform,  340 
Ankle-clonus  in  diagnosis,  539 
Ankle  joint,  radiographic  study  of  epiphyseal 

development  about  it,  596 
Ankylosis,  x-rays  in  diagnosis  of,  687 
Annam  ulcer,  231 
Anthraeosis,  207 
Antisepsis,  66 
.■Antiseptic  and  aseptic,  as  discriminated  in  sur- 

gerj',  695 
Antiseptic   surgery,   its  meaning  as   used   by 

Lister,  695 
Antiseptics,  definition  of,  695 
Antitoxin,  its  bactericidal  action,  418 
Ajjpendicitis,  time  when  operative   treatment 

was  introduced,  58 
Appendix      vermiformis,      removal      of,     by 
Thomas  G.  Morton,  58 

statistics  of  diseases  of,  by  George  Lewis. 
58 
Argyria,  207 

Arteries,  "end"  or  "terminal,"  their  relation 
to  infarctions,  239 

ligature  of,  in  treatment  of  acute  simple 
inflammation,  114 
Arteriohths,  200 

Arthritis,   chronic  non-tuberculous,  i-av   ap- 
pearances of,  656 
Ascites,  definition  of,  236 
Aseptic  closed  wounds,  repair  of,  261 

open  wounds  or  ulcers,  repair  of,  268 

protection  of  the  wound,  273 

surgerj',  the  meaning  of  the  term,  695 
Astrocytes,  derivation  of,  325 
Atrophia  lipomatosa,  166 

musculorum  lipomatosa,  171 

pigmentosa,  165 
Atrophy,  163 

as  it  affects  certain  tissues  and  organs,  170 

brown,  171 


Atrophy,  caused  by  severance  of  nerve  trunk, 
178 
degenerative,  164 
discriminated  from  agenesia,  aplasia,  and 

hjfpoplasia,  164 
from  impaired  nutrition,  168 
from  inactivity  or  disuse,  167 
from  over-activity,  167 
from  pressure,  168 
marantic,  168 
neurotrophic,  170 
nutritive  disorders  leading  to,  165 
pathological,  167 
phj'siological.  166 
with  induration,  cause  of,  165 
Auto-intoxication     exciting     clironic     inflam- 
mations, 139 
Axonal  reaction  of  Jvissl,  after  injury  of  peri- 
pheral nerve,  289 

Babinski's   reflex,   diagnostic  significance   of, 

540 
Bacillus    aiJrogenes  capsulatus    the  cause   of, 
gas-forming  inflammations,  131 
pyocyaneus    the  cause  of    green  or  blue 
pus,  418 
Bacon,  Leonard  Woolsey,  Jr.,  on  general  prog- 
nosis in  surgical  diseases,  771 
Bacteria  in  the  formation  of  pus,  253 

passage  of,  through  sound  mucous  mem- 
branes, 416 
their  sources  and  portals  of  entrance  in 
surgical  infections,  697 
Bacterisemia,  how  produced,  426 

in  inflammation,  96 
Bacterial  e.xamination  of  blood,  its  utility  and 
the  necessarj'  precautions,  559 
infection  as  influenced  by  wound  or  oper- 
ative conditions,  701 
infection,  pathological  changes  following, 

415 
injury  to  tissues,  how  caused,  417 
proteins  and  toxalbumins,   their  produc- 
tion, 417 
Bactericidal  agencies,  sources  of,  89 
Bacteriolysin  and  its  action,  417 
Behla,  x-bodies  of,  388 
BeUe\'ue     Hospital     Jledical     College,     when 

organized,  30 
Benign  and  malignant   growths   of   epithelial 

and  connective  tissue,  types  of.  296 
Beta-oxybutyric  acid  in  the  urine  of  diabetics 

an  unfavorable  prognostic  sign,  794 
BicMoride  of  mercury,  its  use  and  properties 

as  a  disinfectant  of  the  hands,  706 
Bigelow,  Henrj'  J.,  20,  50,  53 
Birth-mark,  320 
Bladder,  diagnosis  of  rupture  of,  550 


INDEX. 


801 


Bladder,  modes  of  diagnostic  examination  of, 

551 
Blastomata,  366 
Blebs,  116 

purulent,  definition  of  the  term,  121 
Bleeding  in  treatment  of  acute  simple  inflam- 
mation, 114 
Blennorrhoea,  definition  of  the  term,  121 
Blisters,  116 

treatment  of,  117 
Blood,  the,  240,  555 
alterations  of,  240 
changes  in,  in  chronic  anaemia,  245 
characteristics  of,  in  secondary  anaemias, 

244 
diseases  of,   in  their  relation  to  surgical 

conditions,  791 
in  the  stools,  its  varied  appearance  and 

sources,  572 
in  the  urine,  its  significance,  571 
regeneration  of,  after  hemorrhage,  245 
simple    tests    of,   as    to    clot  formation, 
fibrin  formation,  etc.,  556 
Blood  corpuscles,  changes  in,  240 
Blood  examinations  in  differential  diagnosis  of 
primary    and    secondary  anaemia,   557 
methods  found  most  important,  55S 
should   be   made   regularly   and  charted, 
558 
Bloodgood,  Joseph  C,  463 
Blood  plates,  their  relation  to  surgical  diseases, 

559 
Bloodless  surgery,  750 
Blood  pressure  in  relation  to  diagnosis,  533 

in  shock,  468 
Blood  supply,  regulation  of,  in  wounds,  274 
Blood-vessels,  asepsis  in  lateral  wounds  of,  288 
conditions  modifying  modes  of  repair  in, 

287 
diagnostic    significance    of    abnormalities 

in,  531 
repair  of,  287 
Body  fluids  in  general  surgical  disease,  with 
special  reference  to  their  diagnostic  value, 
555 
Boils,  128,  129 

Bone,  abscess  of,  treated  by  trephining,  59 
caries  of,  232 
minute  anatomy  of,  279 
regeneration  of,  285,  286 
Bone  atrophy,  172 
concentric,  173 
excentric,  173 

in  ''calcareous  diathesis,"  174 
marantic  form  of,  173 
pressure      form      of,      giving    ''  egg-shell 

crackle,"  174 
x-ray  diagnosis  of,  687 


Bone  blisters,   Codman's,   as  seen  by  aid   of 

x-rays,  665 
Bone   gummata,    as    seen    by   aid   of   x-rays, 

668 
Bone  necrosis,  220,  222 

and  caries  differentiated,  220 
etiology  of,  220 
formation  of  involucrum,  222 
from  phosphorus,  221 
from  traumatism,  221 
Bone  tumors,  x-ray  characteristics  of,  673 
■  Bones,  development  of,  280 

extrinsic  hypertrophy  of,  with  increase  in 
length  from  mechanical  and  chemical 
irritants,  161 
membranous,  280 
Bony  callus  formed  iiia  cartilage,  282 

union,  causes  of  failure  to  secure  it,  284 
Bowels,   overloading  of,   in  their   relation   to 

surgical  prognosis,  790 
Brainard,  Daniel,  27 
Brain  sand  or  psammoma,  200 
Brain,  senile  atrophy  of,  177 
Brashear,  Walter,  60 

Breast,  amputation  of,  during  pregnancy,  779 
tumors  of,  in  mice,  their  infectious  factors, 
393 
Broncholiths,  200 
Brooks,  Harlow,  555 

Brown  induration  resulting  from  passive  con- 
gestion, 236 
Bryant,  Joseph  D.,  501 
Buck,  Gurdon,  52 

Bullae,  purulent — definition  of  the  term,  121 
Bumstead,  Freeman  J.,  37 
Buried   sutures;     the   requirements   answered 
by  catgut,  730 

Calcareous  matter,  deposits  of,  seen  by  aid 

of  x-rays,  687 
Calcification  and  analogous  conditions,  198 

and  petrifaction  contradistinguished  from 
ossification,  200 

chemico-vital  theories  as  to  its  origin,  199 

usually  occurs  in  tissues  already  diseased 
or  the  seat  of  foreign  bodies,  199 
Calculi  or  concretions,  200 

fecal,  203 

hepatic,  200 

pancreatic,  203 

salivary,  203 

urinary,  200,  203 
Callus,  disappearance  of,  282 

external,  as  related  to  the  position  of  the 
fractured  ends  of  bone,  284 

external,  its  earliest  stage,  281 

internal  or  myelogenous,  281 

proportioned  to  deformity,  285 


802 


INDEX. 


Cancer  and  the  acute  exanthemata,  388,  389 

characteristics  of  the  unknown  stimulus  in, 
403 

general  arguments  in  favor  of  its  infec- 
tious nature,  390 

inclusions  in,  387,  389 

in  mice,  evidence  of  an  acquired  immu- 
nity, 399 

in  mice,  its  communicability,  391 

in  mice,  its  spontaneous  retrogression,  398 

parasitical  relations  of,  387,  411 

summary  of  arguments  for  its  infectious- 
ness, 409 

transplantation  experiments,  390 
Cancer  cells,  an  infectious  factor  in  them,  405 

bodies  observed  in  them,  387 

non-chemical  nature  of  their  x-factor,  405 

their  unlimited  power  of  proliferation,  395, 
404 

transferrence  of  their  infectious  factor  to 
normal  epitheliiun,  393 
Cancerous  cachexia,  369 
Caps  for  operative  work,  721 
Carbolic  acid,  its  use  as  a  germicide,  706 
Carbuncles,  128,  129,  130 

staphylococci  most   commonly  found   in, 
130 
Carcinoma,  361 

adenomatosum,  350 

alveolar,  361 

character  of  the  stroma,  360 

colloid  or  gelatinous,  363 

cylindrical-celled,  360 

cylindromatosum,  363 

encephaloid  or  medullary,  361 

extension  by  dissemination,  364 

extension  by  implantation,  365 

extension  by  infiltration,  364 

influence  of   external   traumatism   in   its 
causation,  293 

its  development  from  epithelial  structures, 
354,  355 

its  histological  classification,  358 

its  histological  resemblances,  354 

its  mode  of  growth,  356 

metastasis  in,  364 

methods  of  extension  and  metastasis,  364 

myxomatodes,  363 

round-celled,  359 

secondary  changes  in,  362 

scirrhous,  its  distinctive  features,  361 

squamous-celled    (epithelioma),    358,   359 

umbilicated,  363 

whence  arising,  354 
Carcinoma  cells,  characteristics  of,  356 

degenerative  changes  in,  357 

their  tendency  to  retain  the  character  of 
theparent  cells,  357 


Carcinomatous  growth,  its  atypical  and  aber- 
rant character,  355 
transformation  of  adenoma,  355 
Cardiac  diseases,  a  source  of  danger  in  admin- 
istration of  ansesthetics,  784 
Cargile  membrane,  uses  of,  736 
Caries,  210,  232 

Billroth's  views  of  the  process,  232 
necrotica,  232 
sicca,  232 

sicca,  a>ray  evidence  of,  648 
von    Volkmann's   views     of    the  process, 
232 
Carotid,  common,  ligature  of,  60,  61 
Carpus,    its    development    studied    by   radio- 
graphs, 579 
Carson,  Joseph,  7,  17 
Cartilaginous  exostosis,  315 
Caseation,  215 

a  post-necrotic  process,  216 
miscroscopic  appearances,  216 
Casts  in  the  urine,  their  significance,  570 
Catarrhs,  chronic,  141 
desquamative,   116 
mucous,  116 
purulent,  121,  127 
serous,  116 
Catgut  as  suture  material,  728,  753 
Catgut  preparation  by  Ochsner's  method,  734 

by  other  methods,  730 
Catgut   sterilization  by  the  Bartlett  method, 
733 
by  the  Boeckmann  diy-heat  method,  735 
by  the  Claudius  method  as  modified  by 

Abbott,  732 
by  Konig's  method  and  modifications  of 

it,  735 
by  the  Moschcowitz  method,  732 
by  the  New  York  Hospital  method,  735 
Cautery,  its  uses  and  modern  forms,  767 
Cavernoma,  321 

Cell  proliferation  after  infliction  of  an  injury, 
76,  93 
its   protective   and   sometimes   imperfect 
features,  94 
Cells,  death  of,  necrosis  and  necrobiosis,  183 
division  of,  to  form  new  ones,  257 
multiplication  and  differentiation  of,  147 
Cellular  and  less  cellular  tumors,  295 
Cerebro-spinal   fluid   as   obtained   Ijj'   lumbar 

puncture,  its  diagnostic  value,  560 
Chalicosis,  207 

Charcot's  or  tabetic  joints,  .r-ray  characteris- 
tics of,  668 
Chemical  substances  alone  may  excite  purulent 

inflammation,  126 
Chemotaxis,    a   protective    factor    in    inflam- 
mation, 84 


INDEX. 


803 


Chest  topography,  diagnostic  points  in,  527 
unifoiTnity  of  expansion,   how  interfered 
with,  52S 
Chloroform  ansesthesia  less  dangerous   in    in- 
fants, 774 
and  ether,  their  relative  influence  in  pro- 
ducing shock,  479 
Chloroma,  342 
Chlorosis,  241 

blood-counts  in,  241 
changes  in  the  blood  in,  241 
thrombosis  a  complication  of,  241 
Cholesteatoma,  367 
Cholesterin,  192 
Chondromata,  310,  313 
Chondro-myxoma,  306 
Chondro-myxo-sarcoma,  344 
Chondro-sarcoma,  333,  344 
Chordoma,  311 
Chorio-epithelioma   malignum,    or   deciduoma 

malignum,  368 
Chromato-phoroma,  341 
Chylangiomata,  323 
Cicatricial  tissue,  its  formation,  249 
Cicatrix,  formation  of,  by  secondary  adhesion, 

252 
Circulation,  disturbances  of  the,  233 

mechanism  of  the,  233 
Cirsoid    aneurysm;    angioma    arteriale    plexi- 

forme;  Rankenangiom,   321 
Cleanliness,  surgical,  importance  of,  272 
Climacteric,  the,  effect  of,  upon  neoplasms,  780 
Climate,  influence  of,  upon  results  of  surgical 

operations,  797 
Clinical  instruction,  early  efforts  toward,  29 
Coal  dust  inhaled,  cirrhosis  anthracotica  from, 

208 
Coal  pigment,  absence  of,  in  lungs  of  infants, 

208 
Cohnheim's   developmental   theory   of   tumor 

growth,  293 
Cold  in  treatment  of  acute  simple  inflamma- 
tion, 113 
College  of  Physicians  and  Surgeons,  New  York, 

when  first  organized,  11 
Colliciuative  necrosis  (red  or  yellow  softening) 

of  the  brain,  239 
Colloid  struma,  347 
Color  as  furnishing  diagnostic  aid,  515 
Columbia  College,  New  York,  medical  depart- 
ment of,  organized,  11 
Compression    in    treatment    of    acute    simple 

inflammation,- 115 
Concretions  or  calculi,  198 
Condylomata  acuminata,  331 

as  hyperplasia?  of  connective  tissue,  108 
Congenital  malformations,  x-ray  appearances 

in,  686 


Congestion,  passive,  final  results  of,  236 

gross  appearances  at  seat  of,  236 
Conservatism  in  surgery,  692 
Cornea,  inflammation  of,  76 
Cornification,  193 
Cotton  as  a  dressing,  719 
Councilman's  experiments  on  the  production 

of  pus,  253 
Counter-irritants  in  treatment  of  acute  simple 

inflammation,  114 
Crile's  pneumatic  suit  in  treatment  of  surgical 

shock,  496 
Crystalline  and  amorphous  urinary  deposits, 

their  relation  to  calculi,  571 
Cylindroma,  sarcomatous,  340 
Cyst  contents,  microscopical  and  chemical  ex- 
aminations required  for  diagnosis,  576 
Cystaderio-fibroma,  304 
Cystadenoma  atheromatosum,  348 

mucosum,  348 

ovarian,  352 
Cystomata,  350,  351 

and  cysts,  the  distinction  between,  350 

development  and  characteristics  of,  351 

epithelial  or  proliferation,  350 

glandular  type  of,  451 

of  the  kidney,  353 

ovarian,  351 

papuliferous,  352,  451 
Cysts  of  the  liver,  multiple  congenital,  253 

Dactylitis,  syphilitic,   x-ray  features   of,  670 
Dark-room  for  developing  x-ray  photographs, 

621 
Dartmouth  College,  Hanover,  N.  H.,  medical 

department  of,  organized,  21 
Davidge,  John  B.,  47 

Death,  somatic,  as  distinguished  from  necro- 
biosis and  necrosis,  209 
Decinormal  salt  solution   in  the  treatment  of 

septicaemia  and  pyaemia,  443 
Decubitus  or  bedsore,  137 
Degeneration,  182 
colloid,  190 

distinguished  from  atrophy,  182 
glycogenous,  194 
hydropic,  190 
mucinous,  191,  192 
physiological  and  pathological,  182 
reaction  of,  543 
Degeneration  and  infiltration,  distinction  be- 
tween, 183 
Degenerations     and     infiltrations,     Warthin's 

classification  of,  183 
Degenerative     and     necrotic     inflammations, 

acute,  134 
Delhi  sore,  231 
Deposits,  184 


804 


INDEX. 


Dermatitis,  acute,  as  distinguished  from  ery- 
sipelas, 449 
Dermoid  cysts,  367,  368 
Desault's  method  of  treating  fractures  of  the 

femur,  51 
Detmold,  William,  55 
Diabetes,  effect  of,  upon  surgical  procedures 

and  conditions,  793 
Diacetic  acid  in  the  urine  of  diabetics  an  un- 
favorable prognostic  sign,  794 
Diagnosis,  general  surgical,  501 

special  examination  for,  512 
Diagnostic  examination  of  the  principal  sys- 
tems of  the  body,  516 
Diapedesis  in  inflammation,  85 
Diaphragm  phenomenon,  Litten's,  529 
Diathesis,    influence    of,    upon    surgical    con- 
ditions, 781 
Digestive  system,  its  diagnostic  importance,  516 
Diphtheritic  inflammation,  118 

Bacillus  diphtheria  a  cause  of,  135 
epithelial  or  superficial,  135 
intestinal,  135 

streptococcus  as  a  cause  of,  135 
Disinfectants,   chemical,   in   skin  disinfection, 

705 
Disinfection  and  sterilization,  701 
Dislocations.  47 

of  the  hip  joint,  remarks  on,  by  Nathan 
R.  Smith,  48 
Dodd,  Walter  J.,  599 
Dorsey,  John  Syng,  17,  34,  45 

"Elements  of  Surgery"  by,  34 
Dracuncular  ulcer,  231 

Drainage,  materials  and  methods  of,  now  ap- 
proved, 762 
objections  to  it,  and  conditions  where  in- 
dicated, 764 
secondary',  765 

various  methods    employed    and  the    re- 
sults, 761 
Draper,  William  H.,  16 
Dressings  after  closing  a  wound,  754 
Dry  heat,  the  "baking"  process,  767 
Dudley,  Benjamin  W.,  25 
Dust,  inhalation  of,  protection  against,  208 
Dusting  powders  as  dressings,  722 

ECCHONDROMATA,  311 

Ecchondrosis  physalifera,  of  Virchow,  311 
Effusions  into  the  body  cavities,  effects  of,  238 
Elbow  joint,  its   development  studied  by  ra- 
diographs, 582 
Elephantiasis,  108,  305,  321 
Embolism,  retrograde,  365 
Embryoid  tumors  or  embryomata,  366 
Embryological  classification  of  tumors,    objec- 
tions to  it,  297 


Emprosthotonus  in  tetanus,  457 
Empyemata,  128 

definition  of  the  term,  121 

healing  of,  104 
Enchondromata,  311,  312 

producing  metastases,  312 
Endothelial   cells,   active   functions  of,  in  in- 
flammation, 86 
Endothelioma,  338,  339,  340 
Endothelium,    vascular,    its   secretory   powers 
important    factors    in    the    occurrence    of 
oedemas,  236 
Endurance,  power  of,  greater  in  women,  777 
Enostoses,  314 
Entodermal  cysts,  367 
Environment,     influence     of,     upon     surgical 

prognosis,  795 
Eosinophilia,  246 
Eosinophilic  marrow  cells  found  in  blood  in 

myelocytic  leuksemia,  243 
Epiblastic  structures,  299 
Epidermoid  cysts,  367 
Epiphyfes,  radiographic  interpretation  of,  578       5 1 

of  new-born  child  invisible  in  radiograph,         / 
579 
Epithelial  cells  in  urine,  570 

defect  in  covering  wounds,  274 

growths,  atypical,  355 

pearls  or  cell-nests,  357 

structures  of  typical  growth,  354 
Epithelioma    transformed    into    sarcoma    by 

transplantations,  397 
Epitheliomatous  transformation  of  chronic  ul- 
cers, 231 
Epithelium,  its  power  of  regeneration,  257 

metaplasia  of,  358 
Epulis,  336 
Erysipelas,  445 

as  related  to  pysmia,  450 

bullosum,  130 

constitutional  symptoms  of,  447 

curative  influence  of,  on  other  diseases,  453 

diagnosis  of,  448 

etiology  of,  445 

general  treatment  of,  451 

infectiousness  of,  446 

local  treatment  of,  451 

migrans  or  ambulans,  447 

of  gangrenous  type,  449 

pathological  anatomy  of,  450 

phlegmonous,  447 

prognosis  of,  451 

prophylaxis  of,  451 

serum  therapj^  in,  452 

symptoms  of,  446 

traumatic,  special  features  of,  449 
Erythema    simulating    an    erysipelatous    der- 
matitis, 449 


INDEX. 


805 


Esmarch  bandage,  741 

Ether  as  an  adjuvant  in  disinfection,  708 

Eve,  Paul  F.,  29 

Examination,  general,  of  patient,  505,  507 

Excretions,  567 

Exercise  bone,  315 

Exostoses,  314 

connective-tissue,  315 
or    osteomata,    and    enchondromata,    as 
interpreted  by  x-rays,  671 
Experimental  and  human  wounds,  differences 

in  reparative  processes  in,  263 
Exudates,  574 

inflammatory,   differences  between   them 

and  passive  effusions,  247 
removal  of,  259 

varieties  of,  and  their  characters,  237,  248, 
416,  574 
Eye,  its  external  parts  in  relation  to  diagnosis, 
540 

Face,  inspection  of,  in  diagnosis,  514 
Faces,    deductions   to   be    drawn   from   their 
gross  appearances,  571 

value  of  bacterial  examination  of,  574 
Faintness,  or  ischsemia  of   the  brain,  239 
Fat  necrosis,  216 

associated  with  pancreatic  lesions,  217 

researches  of  Hildebrand  and  Flexner,  217 

microscopic  characters  of,  185 
Fatty  infiltration,  187 
Fatty  degeneration,  causes  of,  185,  187 

gross  appearances  of,  189 

microscopical  appearances  of,  189 

presence  or  absence  of   ovaries  or  testes 
related  to,  188 

rationale  of  fat  accumulation,  188 

results  of,  189 
Felon,  128,  129 

Femur,  its  epiphyseal  development  as  shown 
by  radiography,  592 

treatment  of  fracture  of,  51,  52 
Fever  following  operation,  535 

of  suppuration,  535 
Fibrin,  its  removal  and  changes,  260 
Fibro-adenoma,  346 
Fibro-lipoma,  307 
Fibro-myxoma,  306 
Fibro-sarcoma,  333,  335 
Fibroids  of  the  uterus,  303 

removal  of,  during  pregnancy,  779 
Fibroma,  301,  302 

cavernosum,  303 

diffusum,  304 

durum,  302,  305 

intracanalicular,  304 

lipomatodes,  303 

lymphangiectaticum,  303 


Fibroma  moUe,  302 

•nodular,  304 

of  peripheral  nerves,  305 

of  the  breast,  304 

ossificum,  303 

pedunculated,  303 

pericanalicular,  304 

petrificum,  302 

plexiform  (Ranken-neurom),  305 

retrogressive  changes  in,  303 

teleangiectatic,  303,  319 

tuberosum,  304 
Filtration  experiments,  significance  of,  406 
First  intention,  healing  by,  100,  249,  261,  265 
Fistula,  133,  255 

following  deep-seated  infection,  419 

resulting  from  suppuration,  121 
Fitz,  R.  J.,  on  perforative  inflammation  of  the 

vermifonn  appendix,  59 
Fixation  of  wounded  tissue,  273 
Ford's  experiments  to  prove  the  presence  of 

bacteria  in  healthy  tissues,  253 
Foreign  bodies,  disposal  of,  in  healing,  105 
Foreign-body  giant  cells,  106 
Fractures,   immobilization  essential   in   treat- 
ment of,  285 

repair  of,  279,  280 

a--ray  diagnosis  of,  643 
Fragilitas  ossium  or  periosteal  dysplasia,  and 
osteogenesis  imperfecta,  .-c-ray  features  of,  685 
Free-bodies,  sometimes  wholly  organic,  200 
Fungous  or  exuberant  ulcer,  229 
Furuncles,  128,  130 

a  result  of  bacterial  inflammation,  418 

Gaboon  ulcer,  231 

Gait,  its  diagnostic  significance,  538 

Gall  stones,  201 

Gangrene,  136 

black,  137 

circmnscribed,  136 

diabetic,  136 

diffuse,  136 

dry,  136,  137,  218 

emphysematous,  137 

hospital,  three  forms  of,  422 

idiopathic,  136 

moist,  136,  137,  218 

neuropathic,  136 

noma,  219 

phagedenic,  136 

primary,  specific  infections  causing,  217 

resulting  from  permanent   arrest   of   cir- 
culation, 236 

secondary,  causation  of,  218 

senile,  136 

synonyms,  217 

thermal,  136 


INDEX. 


Gangrene,  toxic,  136 
traumatic,  136 
white,  137 
Gangrene  foudroyante,  421 
Gangrenous  inflammation,   primary   and   sec- 
ondary, 136 
Gastric  juice,  importance  of  examining  it  in 
diagnosis  of  carcinoma  of  the  stomach, 
562 
testing  its  peptic  capabilities,  562 
Gauze  as  a  dressing,  718 

as  directly  applied  to  sterile  wounds,  755, 

759 
bandages,  719 
Gaylord,  Harvey  R.,  3S7 
Genital  tract,  female,  secretions  of,  565 

male,  secretions  of,  566 
Genito-urinary  organs,  consideration  of,  from 

a  diagnostic  point  of  view,  545,  550 
Giant  cells,  mononuclear,  88 
Gibson,  William,  18,  34 

Gigantism,  an  example  of    intrinsic    congeni- 
tal hypertrophy,  151 
Glioma,  324 

and  sarcoma,  their  relationship,  326 
differentiation  of  various  forms  of,  325 
durmn,  324 

epend\^nal  (Flexner),  326,  327 
etiology  of,  327 
malignant,  327 
moUe,  324 

of  the  retina,   description  and  classifica- 
tion, 326 
results  of,  327 
teleangiectaticum,  324 
Gliosis  occurring  with  syringomyelia,  327 
Glycosuria,  its  surgical  significance,  569 
Goitre,  colloid,  191 

cystic,  347 
Gout,  a;-ray  characteristics  of,  660 
Granulating  wounds,  local  infections  of,  422 
Granulation  tissue,  its  character  and  conver- 
sion into  scar  tissue,  93,  251,  263 
Granulomata,  infective,  as  sequelae  of   an  in- 
fective inflammation,  108,  144 
Graves'  disease,  influence  of,  in  surgical  opera- 
tions, 791 
Gross,  Samuel  D.,  14,  27,  35 
Gums,  diagnostic  indications  which  thej'  fur- 
nish, 517 
Gunn,  Moses,  49 
Gynaecology  as  a  special  branch  of  surgerj',  56 

Habits  as  bearing  on  diagnosis,  509 
Hsemangioma,  319,  321 

arteriale,  320,  321 

cavernosum,  320 

simplex,  320 


Hsemangioma  venosum,  321 
Haemochromatosis,  205 

Haemocytology  in  its  relation  to  surgical  prog- 
nosis, 791 
Hcemoglobin,  importance  of  knowing  percent- 
age of,  in  chlorotic  anaemia,  556 
in  differential  diagnosis  of  malignant  and 
innocent  neoplasms,  556 
Hajmoglobinaemia,  205 
Hemoglobinuria,  205 

Haemophilia,  hereditary,  importance  of,  in  sur- 
gical prognosis,  783,  792 
Haemostasis,  complete,  a  surgical  principle  in 

treatment,  273 
Haemostatic  forceps,  746 
Hamilton,  Frank  H.,  36 
Hand  steriHzation,  conclusions  concerning,  703, 

708 
Harrington's  solution  of  bichloride  of  mercury 

for  sterilizing  the  hands,  706 
Harvard  College,   Cambridge,   Mass.,   medical 

department  of,  organized,  10 
Haj'ward,  George,  20 
Hearing,  sense  of,  and  its  defects,  as  concerned 

in  diagnosis,  542 
Heart,  atrophy  of,  171 

repair  of  injury  of,  287 
Heat,  a  symptom  of  irJlammation,  94 
and  cold,  surgical  uses  of,  765,  766 
in  treatment  of  acute  simple  inflamma- 
tion, 113 
Heat   sense    (thermo-aesthesia)   in   relation   to 

diagnosis,  537 
Hemorrhages,     repeated     small,     leading     to 

chronic  anaemia,  245 
Hemorrhagic  exudate,  416 
Heredity,  influence  of,  upon  surgical  conditions, 

782 
Hernia  as  affected  by  parturition,  780 
Hickey,  Preston  M.,  578 
Hip  joint,  Alden  March's  treatment  of  disease 
of,  by  fixation  and  traction,  54 
amputation  at,  60 
disease  of,  54 
dislocations  of,  4S 

Physick's  method  of  treating  disease  of,  54 
Sayre's  splint  in  treatment  of  disease  of,  55 
Horsehair  for  sutures,  726 
Howell,  W.  H.,  on  the  cause  of  shock,  464 
Hyalin,  epithelial,  192 

resemblances  and  differences  between  it 
and  amyloid,  197 
Hydatidiform  mole   or  myxoma   chorii   race- 

mosum,  307 
Hydraemia  defined,  240 
Hydrocele.  236 

Hydrocephalus,  external,  definition  of,  236 
internal,  definition  of,  236 


INDEX. 


807 


Hydropericardium,  definition  of,  236 
Hydrotliorax,  definition  of,  236 
Hygroma  colli  congenitum,  323 
Hylomata  or  pulp  tumors,  298 
HyperEemia  or  congestion,  234 
active,  causes  of,  234 
arterial,  effects  due  to,  235 
following  infection,  415 
local,  passive  or  venous,  234 
Hypernephroma,  benign,  347 
Hyperostosis,  314 
Hypertrophy,  148 

compensatory,  as  when  fibula  is  thickened 

on  weakening  of  tibia,  156 
complemental,    as    between   thyroid    and 

pituitary  body,  156 
due  to  errors  of  metabolism,  162 
extrinsic,  153,  154,  155 
from   chronic    irritation,    as   intermittent 

pressure,  159 
from  failure  of  involution,  as  sometimes 
occurs    in    the    thymus    gland    or    the 
uterus  post  partum,  157 
from  increased  nutrition,  as  by  enlarged 

blood-vessels,  158 
from  removal  of  pressure,  as  in  a  micro- 
cephalic skull  when  brain  is  undeveloped, 
159 
from  removal  of  pressure,  as  in  the  over- 
growth of  fat  about  a  contracted  kidney, 
157 
influence    of    the    ductless    glands    upon 

extrinsic,  162 
intrinsic,  151 

mutual  relations  between  growth  and  de- 
velopment, 149 
neurotrophic,  as  in  a  hypertrophied  blad- 
der in  children,  163 
numerical,  or  hyperplasia,  150 
quantitative,  or  true  hypertrophy,  150 
Hypoblastic  structures,  299 

Ichorous  pus  defined,  253 
Icterus  or  javmdice,  causes  of,  206 
Iliac,  primitive,  ligation  of,  44 
Implantation  in  mice,  natural  immunity  to,  397 
Inclusions  in  cancer,  question  of  their  para- 
sitic nature,  388 
Indican,  significance  of,  in  urine,  569 
Infants  less  liable  to  nervous  shock,  774 

plastic  operations  upon,  774 
Infarct,  ansmic  or  white,  explanation  of  the 
term,  239 

red  or  hsemorrhagic,  its  origin,  239 
Infected  wounds,  271 
Infection,  696 

from  the  mouth  and  upper  air  passages,  699 

of  a  healing  wound,  418 


Infection  of  closed  wounds,  effects  of,  271,  272 
of   wounds,   conditions   favorable   to   the 

development  of,  699 
resisted  by  granulation  tissue,  274 
sources  of,   and  the  prophylaxis  against 

them,  696 
through  orifices  of  glands  and  other  nat- 
ural openings,  697 
Infections,  diseased  conditions  favoring  their 
development,  700 
which  sometimes  occur  in  various  surgical 
diseases  and  conditions,  415 
Infectious  arthritis,  a:-ray  indications  of,  659 
Infectious  diseases,  acute,  influence  of,  upon 

surgical  conditions,  792 
Infectious  venereal  granuloma  of  the  dog,  407 
features  distinguishing  it  from   true   ma- 
lignant tumors,  408 
its  analogies  to  sarcoma,  409 
Infective    agents — the    most    important    bac- 
teria, 415 
Infective    granulomata,    distinctions    between 

them  and  tumors,  291 
Infective    susceptibility   of    different   tissues, 

700 
Infiltrations,  194 

amyloid,     etiologically     connected     with 

chronic  cachexias,  195 
glycogenous,  203 
hyaline,   exact  nature  of,   undetermined, 

197 
pigmentary,  203 
purulent,  121 
small-celled,  121 
Inflammation,  71 

a  bodily  function,  fundamentally  protec- 
tive, with  varying  manifestations,  81 
acute  degenerative  and  necrotic,  134 
acute  fibrinous,  118 
acute  purulent,  121 
acute  serous,  115 
adhesive,  104 

as  defined  by  various  modern  authors,  75 
aseptic,  110 

Boerhave's  conception  of,  73 
certain  products  of,  247 
chronic  atrophic,  144 
chronic  indurative,  145 
chronic  infections  a  cause  of,  139 
chronic  intoxications  a  cause  of,  139 
chronic  productive,  145 
Cohnheim's  conception  of,  73 
croupous,  118 
definition  of,  71 
diphtheritic,  135 

discrimination  between  pyogenesis  and,  75 
etiology  of,  81 
extracellular  protective  factors  in,  89 


INDEX. 


Inflammation,  factors  concerned  in,  82 
,  fibrino-purulent,  122 

fibrinous,  119 

fluid  exudate  in,  90 

formative,  110 

gangrenous,  137 

healing  of,  100 

kept  up  by  repeated  mechanical  injury, 
139 

local,  general  effects  of,  upon  the  organ- 
ism, 96 

local  treatment  of,  109,  110,  111,  112 

membranous,  118 

modifying  influences  of,  81 

necrotic  tissue  as  a  cause  of,  139 

nervous  origin  of,  90 

phlegmonous,  131 

protective  factors  in  the  process,  8-4 

purulent,  121 

reparative  agencies  in,  253 

Rokitansky's  conception  of,  73 

sequelae  of,  107 

sero-purulent,  121 

symptomatology,  94 

table  of  varieties  of,  97 

the  term  as  applied  by  Celsus,  72 

variations  due  to  modifjang  factors,  80 

vascular  changes  in,  84 

Virchow's  conception  of,  73 
Innominate  artery,  ligature  of,  42,  43 
Inspection,  diagnostic  data  acquired  by,  512 
Instruments,  741 

Intestinal  epithelium,  regeneration  of,  258 
Intestines,    examination    of,    and    diagnostic 
data  obtainable  from,  524 

■n-ounds  of,  275,  276 
Intravascular  antisepsis  in  the  treatment  of 

septica?mia,  444 
Involucrum  as  a  periosteal  reproduction,   286 
Iodine  as  a  sterilizing  agent,  707 
Iodoform  emulsion,  its  use   in   treating  cold 
abscesses,  723 

gauze,  its  uses  and  preparation,  723 

value  of,  as  a  dressing,  723 
lodophilia,  inferences  to  be  drawn  from,  559 
Irrigation,  when  and  how  to  be  used,  704 
Irritants,  reaction  of  cells  to  them  in  inflam- 
mation, 71 
IschEemia,  defined,  240 

and  ansemia,   distinction  drawn  between 
them,  238 
Isodiametric  cells,  359 

Jackson,  Charles  T.,  66 
Jackson,  James,  11 
Jameson,  Horatio  Gates,  45 
Jaundice,  liEemo-hepatogenous,  206 
obstructive,  206 


Jefferson    Jledical    College    of    Philadelphia, 

when  founded,  26 
Joints,  suppuration  ■nithin,  results  of,  255 
Jones,  John,  8,  34 

Kangaroo  tendon  for  buried  sutures,  730 

Karj^okinesis,  257 

Kelly,  Howard  A.,  4 

Keloid,  idiopathic  or  spontaneous,  305 

secondarj',   sear,   cicatricial,   or  spurious, 
305 
Kidney,  diseases  of,  a  source  of  danger  in  ad- 
ministration of  anesthetics,  785,  787 
epithelium  of,  its  limited  power  of  repair, 

258 
examination    of,  as    to    its    mobility  and 
pathological  relations,  552 
King's  College,    New  York,   medical    depart- 
ment of,  organized,  8 
Knee-jerk,  or  patellar  reflex,  as  a  diagnostic 
factor,  539 
loss    of,    in    alcoholism,    an    unfavorable 
prognostic  sign,  797 
Knee  joint,  development   of  epiphyses  about 

it,  as  shown  by  radiographs,  592 
Ivnight,  Jonathan,  22 
Knives,  surgical,  743 
Koellicker's  chromatophores,  194 
Krj'oscopy  of  the   blood  and  of  the  urine,  560 

Lactation,  prolonged,  effects  of,  780 

Laudable  pus,  125 

Leiomyoma  (myoma  laevicellulare),  316 

causing  metastases,  319 
Leontiasis    ossea,    an    instance    of    localized 

intrinsic  hj^ertrophy,  153 
Lepidomata  or  "  rind"  tumors,  297 
Leucocytes,  assemblage  of,  in  vicinity  of  in- 
jurjf,  76 
diagnostic  value  of  differential  counts  of, 

558 
emigration  of,  85 
marginal  chsposition  of,  in  inflammation, 

85 
removal  of,  by  phagocytosis,  2S0 
Leucocytosis,  240,  245 

degree  of,  important  in  surgical  prognosis, 

792 
diagnostic  value  of  its  presence  and  degree, 

558 
in  infancy,  246 
inflammatory,  246 
non-pathological    conditions    leading    to, 

559 
of  digestion,  246 
pathological,  causes  of,  246 
physiological,  246 
produced  by  certain  drugs,  246 


INDEX. 


809 


Leucocytosis,   several    counts    necessary,    to 
guard  against  exceptional  conditions,  558 
toxic,  246 
Iieucopenia  defined,  240 

Leukaemia,     acute    lymphatic,     characteristic 
symptoms  of  the  disease,  242 
acute    lymphatic,     or    acute     lymphocy- 

thsemia,  242 
chronic   lymphatic,    characteristic    symp- 
toms of  the  disease,  242 
divided   opinions   as   to   its   pathological 

relations,  244 
features  of  the  predominating  type,  241 
importance  of  blood  examination  in,  241 
lymphatic,    features    of    the    leucocytosis 

in  this  disease,  242 
modifications   of   the   blood  in,  from  in- 
flammatory process,  244 
myelocytic,  course  of  the  disease,  242 
myelocytic,  diagnostic  importance  of  the 

leucocytes  in,  243 
myelocytic,   features   of   the   blood-count 

in,  243 
myelocytic,  types  of  myelocytes  found  in 

this  disease,  243 
myelogenous,    characteristic    changes    in 

bone  marrow  in,  243 
the  blood  picture  of,  modified  by  use  of 
arsenic,  244 
Lewis,  George,  58 

Libraries,  medical,  in  the  United  States,  38 
Ligatures  and  sutures,  materials  employed,  724 
animal,  suggested  by  Physick,  45 
carriers,  747 
Lipomata,  189,  307 
causation  of,  310 
myxomatodes,  310 
retroperitoneal,  309 
teleangiectatic,  319 
Lipo-myxo-sarcoma,  344 
Lipo-sarcoma,  333 

Lips,  data  furnished  by  them  in  diagnosis,  516 
Liquor  puris,  252 
Lister,  Joseph,  691 

Litholapaxy,  developed  by  Bigelow,  53 
Lithotomy,  53 

Liver,  abnormal  relations  of,  and  their  diag- 
nostic significance,  522,  790 
epithelium  of,  its  regeneration,  258 
lesions   of,    in   their  relations   to   surgical 
prognosis,  790 
Liver  atrophy,  181 

acute  yellow,  181,  206 
melanaemic,  181 
Locality,  sense  of,  in  relation  to  diagnosis,  537 
Long,  Crawford  W.,  64 

Louisiana,  medical  department  of  University 
of,  organized,  28 


Low-pressure  steriHzers,  716 
Lungs,  atrophy  of,  172 

LjTnph,  plastic  or  coagulable,  distinctive  char- 
acter of,  247 
organization  of,  in  an  incised  wound,  248 
Lymph    channels,    dift'usion    of   inflammatory 

products  bj',  91 
Lj-mph  nodes,  Ribbert's  views  regarding,  87 
Lymphangioma  or  angioma  Ipnphaticum,  319, 
322^ 
cavemosum,  323 
cystoides,  323 
etiology  of,  323 
Lymphangitis,  422 

a  frequent  complication  of  felons,  131 
ascending,  92 
LjTnphatic  nodes,  atrophy  of,  180 
Lymphatic  sj-stem,  part  played  by,  in  inflam- 
mation, 91 
protective  functions  of,  in  inflammation, 
92 
Lymphocytes,   appearance  and  source  of,   in 

inflammation,  87 
Lymphocytosis,  246 

Lymphogenous  matastasis  in  inflammation,  96 
LjTnpho-sarcoma,  334 
LjTnphosporidium   truttte,    the   relative   sizes 

of  its  difi^erent  forms,  406 
Lysol  as  a  disinfectant,  707 

Macrocheilia,  323 

Macroglossia,  317,  323 

Malignant  diseases,  heredity  of,  783 
oedema,  bacillus  of  (Koch),  421 

Mahmi  perforans,  137 

Mamma,  atrophy  of,  182 

Mamraarj^  secretion,  564 

in  functional  inactivity,   diagnostic  data 
to  be  obtained  from,  564 

Manipulation,  avoidance  of,   a  surgical  prin- 
ciple, 273 

Manipulations,    reduction    of    dislocations    of 
hip  joint  b}^  48 

March,  Alden,  53 

Marrow  cell  of  Cornil  found  in  blood  of  myelo- 
cytic leukaemia,  243 

Martin's  rubber  bandages,  741 

Masks  for  operative  work,  721 

McBurney,  Charles  C,  59 

McClellan,  George,  26 

McGraw,  Theodore  A.,  370 

Melanin,  characteristics  of,  342 

Melano-carcinoma,  363 

Melanoma,  341 

Melano-sarcoma,  341 

Menstruation,  influence  of  operations  upon,  778 

Mental  disorders,  effects  of  operations  upon,  788 

Mesenchymal  tissues,  reproduction  of,  258 


810 


INDEX. 


Mesoblastic  structures,  299 

Mesodermal  cysts,  367 

Metastases  of  the  liver  in  pyaemia,  437 

of  the  lung  in  pysemia,  437 

of  tumors,  Virchow's  views,  379 
Metastatic  calcification,  or  lime  metastasis,  199 
Methfemoglobinuria,  205 
Miami  Medical  College,  organization  of,  23 
Micromonas  Mesnili,  relations  of,  to  sheep-pox, 

406 
Micro-organisms,  pyogenic,  125 

constantlj'  present  upon  the  skin,  126 
Micturition,  difficult,  causes  and  relations'  of, 
548 
_  diminished  frequency  of,   its  causes  and 
significance,  546 

frequent,  its  diagnostic  indications,  546 

interrupted,  its  causative  and  diagnostic 
relations,  548 

involuntarj',  its  causation  and  diagnostic 
relations,  549 

irrepressible,  its    causes    and  occurrence, 
547 

painful,  causation  and  diagnostic  impor- 
tance, 549 

retarded,  causes  and  diagnostic  relations, 
548 

urgent,  its  causative  relations,  547 
Milliammeter,  616 
Mitosis,  257 

Mollifies  ossium  or  halisteresis,  174 
MoUuscum  fibrosum,  305 
Moore,  James  E.,  691 
Morgan,  John,  7 
Morton,  Thomas  G.,  58 
Morton,  W.  T.  G.,  64 
Mother's  marks,  321 
Motion,  its  significance  in  diagnosis,  538 
Mott,  Valentine,  5,  12,  13,  42,  44 
Moiise  tumors,  histological  characteristics  of 
those  retrograding,  399 

vaiying  success  in  transplanting  them,  394 
Mouth,  blood  expelled  from  the,  its  sources 

and  diagnostic  significance,  521 
Mucoid  tissue,  its  character  and  relations,  306 
Muco-pus  defined,  253 
Mucous  membranes,  disinfection  of,  708 

fibrinous  exudate  on,  118 

superficial  exudative  inflammation  of,  250 
Mucus  in  the  stools,  its  significance,  573 
Muscle,  absence  of  regeneration  in,  259 

as  affected  by  atrophy,  170,  171 

repair  of,  287 
Museums,  pathological,  value  of,  33 
Mussey,  Reul^en  D.,  23 
Myo-fibroma,  318 

teleangiectatic  and  cavernous,  303 
Myoma,  316 


Myoma,  etiology  of,  319 

histology  of,  318 

molle,  318 
Slj'opathy,   primary,   or  progressive  muscular 

dystrophy,  171 
Myo-sarcoma  or  myoma  sarcomatodes,  344 
Myositis  ossificans,  315 
Myxo-chondroma,  311 
Myxoedema,  influence  of,  in  surgical  conditions, 

791 
Myxo-lipoma,  307 
Myxoma,  306 

lipomatodes;  lipo-raj^xoma,  306 

of  mucous  membranes,  307 

teleangiectatic,  319 
Myxo-sarcoma,  307,  333,  344 

NiEvus  flanmieus,  320 

lymphaticus,  323 

prominens,  321 

vasculosus,  320 
Nails  and  screws,  their  disadvantages  in  treat- 
ment of  fractures,  749 
Narcosis,  interrupted,  as  related  to  the  pro- 
duction of  shock,  475 
Nasal  secretion,  diagnostic  data  from  cerebro- 
spinal fluid  foimd  in  it,  563 

indications  of  pus  in,  563 

its  study  for  diagnosis,  563 
Neck,  inspection  of,  in  diagnosis,  514 
Necrobiosis  and  necrosis,  208 

characteristics  and  course  of,  209 
Necrosis,  213 

caustics  causing,  211 

coagulation,  214 

cold  as  a  cause  of,  211 

colliquative,  215 

distinguished  from  gangrene,  209 

due  to  interference  with  blood-supply,  21 1 

heat  as  a  cause  of,  211 

liistological  changes  in,  210 

inflammation  as  a  cause  of,  212 

neurotrophic,  212 

of  bone,  molecular  (von  Volkmann),  232 

toxic  agencies  causative  of,  212 

traumatic  insults  causing,  210 

a; -rays  as  a  cause  of,  211 
Necrotic  areas,  healing  of,  105 
Needle-holders,  their  requirements,  745 
Needles,  essential  features  of,  744 
Negro,    immunity    of,    in    respect    of    certain 

diseases,  784 
Neoplasms,  effect  of  the  climacteric  upon,  780 
Nerves,  degenerative  changes  in,  due  to  toxins, 
bacteria,  nutritive  and  circulatory  disor- 
ders, 179 

peripheral,   degeneration   associated   with 
atrophy  of,  178 


INDEX. 


811 


Nerves,  peripheral,  injuries  of,  2S9 

rate  of  regeneration  of,  290 
Nervous  diseases,  effect  of,  upon  surgical  prog- 
nosis, 7SS 
Nervous  system,  atrophy  of,  175,  176 

degenerations  of,  primary  and  secondary, 
176,  177 

in  relation  to  diagnosis,  535 

part  .played  by,  in  inflammation,  90 

repair  of  injuries,  290 
Neurasthenia,  effect  ot,  upon  surgical  condi- 
tions, 7S9 
Neuro-epitheliomata,  326 
Neuro-fibroma,  305 

Neuroglia,  Weigert's  views  of  the  cells  of,  325 
Neuroma,  328 

amputation,  328 

ganglionic,  329 

multiple  cutaneous,  329 

of  the  central  nervous  system,  329 

plexiform  (Rankenneurom),  329 
Neuropathic  atrophies,  muscles  involved  in,  171 
Neurotization  of  sear,  290 
Neutrophilic  marrow-cells  (Ehrlich's  Markzelle) 

found  in  blood  of  myelocytic  leukEemia,  243 
Nicholls,  Albert  G..  146,  291 
Nichols,  Edward  H..  256 
Noma,  137,  220 

Non-vascular  tissues,  effects  of  injury  upon,  76 
Nurses,    training   school   for,    inaugurated   in 

Bellevue  Hospital,  32 
Nutrition,  disturbances  of,  in  connection  with 
surgical  diseases  and  conditions,  146 

Obstipation  in  its  relation  to  surgical  prog- 
nosis, 790 
Occupation  as  related  to  chagnosis,  508 
Ochronosis,  194 
Odontoma,  314 
CEdema  or  dropsy,  236 
acute  purulent,  420 

a  result  of  general  passive  congestion,  237 
factors  determining  the  occurrence  of,  236 
inflammatory,  116,  236,  237 
local,  from  local  passive  congestion,  237 
lymphatic,  236 

purulent,  definition  and  etiology  of,  121 
results  of,  238 
OEdemas   sometimes  due  to  altered  secreting 

powers  of  vascular  endothelium,  237 
CEclematous  tissues,  microscopical  features  ot, 

238 
ffisophagus,    its    examination   and   diagnostic 

data,  518 
Old  people,  operations  upon,  776 
Oligaemia  defined,  240 

Oophorectomy,  performance  of,  during  preg- 
nancy, 779 


Open  wounds,  infection  of,  272 
Operating  gowns,  721 

Operations,  diseases  which  enhance  the  dan- 
gers of,  786 

effect  of,  upon  neurasthenia,  789 

influence  ot  age  upon,  772 

influence  ot  menstrviation  upon,  778 

influence  of,  upon  pregnancy,  778 

rendered  more  dangerous  by  various  dis- 
eases, 786 
Operative  facility,  its  dangers,  693 

procedures  in  aid  ot  diagnosis,  553 
Opisthotonus  in  tetanus,  457 
Orthodiagraph,  630 
Orthopedic  surgery,  55 
Osgood,  Robert  B.,  599 
Osteitis  deformans   or   Paget's  disease,  x-ray 

evidences  of,  674 
Osteoarthropathie  hypertrophiante  pneumique, 

686 
Osteoblasts  and  osteoclasts,  their  action,  282 
Osteo-chondroma,  311 
Osteogenesis  in  chronic  bone  diseases,  161 
Osteogenetic  tissues,  their  repair,  280 
Osteoid,  development  of,  281 

tumors,  distinguisliing  characteristics  ot, 
315 
Osteoma,  313,  314 

continuous,  314 

dental,  314 

discontinuous,  314 

eburneum,  313 

spongiosum  or  medullary  osteoma,  313 
Osteomalacia,  174 

x-ray  features  ot,  676 
Osteomyelitis,  chronic  circumscribed,  as  shown 
by  x-ray,  654 

chronic  diffuse,  as  sho-mi  by  x-ray,  654 

diffuse  sj'philitic,  668 

x-ray  diagnosis  ot,  649 
Osteophytes,  314 
Osteoporosis,  165,  173 
Osteopsathyrosis,  or  tragilitas  ossium,  175 
Osteo-sarcoma,  333,  344 
Osteosclerosis,  162 
Otoliths,  200 
Ovaries,  atrophy  ot,  181 
Ovariotomy,  61 

Overproduction  of  tissue  as  a  s?quela   of   in- 
flammation, 108 

Pagenstecher's  celluloid  yarn,   its  prepara- 
tion and  use  in  sutures,  727 
Pain,  95 

differences  in  sense  ot,  537 
seat  of,  as  an  element  in  diagnosis,  536,  537 
Palate,  tonsils,  and  pharjmx,  diagnostic  indi- 
cations furnished  by,  517 


812 


INDEX. 


Palpation,  its  use  in  diagnosis,  515 
Panaritium,  130 
Pancreas,  adenoma  of,  345 
Papillary  naevi,  329 
Papuliferous  cystadeno-fibroma,  304 
Papillomata,  329 
etiology  of,  331 

intracanalicular,  of  the  mamma,  351 
of  mucous  surfaces,  329 
of  the  bladder,  330 
Paralytic  degeneration  of  nerve,  following  in- 
jury, 289 
Parasites  to  be  sought  for  in  the  fteces,  573 
Parker,  WiUard,  15 
Paronychise,  418 
Parturition,  effect  of,  upon  surgical  conditions, 

780 
Patellar  reflex,  absence  of,  in  diabetes,  an  un- 
favorable prognostic  sign,  793 
Pathogenic   bacteria,   differences  in  the  viru- 
lence of  their  infectiveness,  700 
Pathology,  surgical,  69 

Pelvic  diagnosis  by  rectal  examination,  525 
Peimsylvania,   University  of,    organization  of 

medical  department,  11 
Perinaeum,   its   examination   for   diagnosis   of 

urinary  extravasation,  550 
Periosteal  regeneration  of  a  bone  in  likeness 

of  the  original,  286 
Periosteum   and   endosteimi,    their   power   to 
regenerate  bone  after  death  of  a  portion,  286 
Perithelioma,  malignant,  340 
Peritonitis,  simple,  development  of,  249 
Pernicious  anaemia,  characteristic  changes  in 

the  blood,  241 
Peroxide  of  hydrogen  as  a  cleansing  agent,  70S 
Personal  history  of  patient,  its  importance  in 

diagnosis,  509,  510 
Perthes'  experiments  with   the  .-c-ray  on  warts, 

402 
Petrifying  infiltrations,  198 
Phagocytosis,  a  protective  agency  in  inflam- 
mation, 74,  89 
Philadelphia,  College  of,  organization  of  medi- 
cal department  of,  7 
Phleboliths,  200 
Phlegmonous  inflammation,  121,  418,  420 

septicaemia  often  present  with,  131 
Physick,  Philip  Syng,  16,  54 
Pigmentary  deposit,  biliary,  205 

substances  inhaled,  chronic  fibroid  pneu- 
monia from,  208 
Pigmentation,  biliary,  203 

by  extraneous  pigments,  193,  207 

by  way  of  the  alimentarj'  tract — metals, 

207 
by  way  of  the  lungs  (pneumonokoniosis), 
207 


Pigmentation,  cachectic,  207 

conditions  under  which  it  is  physiologi- 
cally or  pathologicall}-  increased,  193 
from  cellular  activity,  193 
hematogenous,  203,  204 
in  chloroma,  194 
in  jaundice  or  icterus,  193 
of  organs  in  which  pigment  exists  nor- 
mally, 193 
of  the  liver,  205 
of  the  skin,  by  tattooing,  207 
origin  of  the  hsematogenous  variety,  204 
transferrence    of,  to   spleen,  from   a   sar- 
coma, 205 
Pigments,  autochthonous  or  metaljolic,  193 
Pilcher,  Paul  Monroe,  415 
Plasma  cells,  characteristics  and  source  of,  88 
Plasmodiophora  brassica;,  388 
Plaster-of-Paris  bandages,  how  prepared  and 
used,  738 
dressings   in   tuberculous   joints,    and   in 
fractures,  740 
Plastic  or  fibrinous  exudate,  248 
Plethora,  234,  240 
Pleuritis,    purulent,    anatomical   changes    in, 

140 
Plimmer's  .bodies,  381,  388 
Polycythsemia  defined,  240 
Pope,  Charles  A.,  29 
Port-wine  stain — nEe\Tis  vinosus,  320 
Post,  Wright,  12,  40 

Potassiimi  permanganate  and  oxalic  acid  or 
the  Schatz  method  of  sterilizing  the  hands, 
707 
Pott's  method  of  treating  fractures  of  femur,  51 
Poultices,  759 

Pregnancy,   influence   of,   upon  neoplasms  of 
the  reproductive  organs,  779 
influence  of,  upon  operations,  778 
Prickle  cells,  359 

Prognosis,  general,  in  surgical  diseases,  771 
Proliferation  of  epithelial  and  connective-tissue 

cells,  262 
Prostate,  atrophy  ol,  181 

examination   of,   for  diagnostic  pui-poses, 
550 
Prostatic  secretion,  manner  of  obtaining  and 

findings,  566 
Proud  flesh,  251 
Psammoma,  340 
Pseudo-arthrosis  defined,  284 
Pseudo-chylous   ascites,    from   obstruction   of 

thoracic  duct,  237 
Pseudo-hypertrophic  muscular  paralysis,   171 
Pseudo-leuka?mia  or  Hodgkin's  disease,  244 
Pseudo-membrane  in  inflammation  of  mucous 

membranes,  250 
Ptomains,  how  produced,  417 


INDEX. 


813 


Puerperal  septicaemia,  local  treatment  of,  442 
Pulse  as  an  aid  in  diagnosis,  533 
Pupil,  Argyll-Robertson,  541 

its  diagnostic  indications,  540 
Purulent  exudates,  details  of  the  examinations 
required,  576 

removal  of,  260 
Purulent    inflammation   may   be    excited    by 

simple  chemical  substances,  126 
Pus,  121,  252 

association  with  granulation  tissue,  251 

blue,  253 

bonum  vel  laudabile,  character  and  con- 
stituents of,  125,  252 

cellular  constituents  of,  124 

curdy,  253 

entrance  of,  into  the  blood,  255 

formation  of,  416 

in  the  urine,  its  sources  and  significance, 
571 

physical  characteristics  of,  123 

production   of,    a   protective   reaction   to 
injury,  125 

red,  Ferchmin's  description  of,  254 

sanious,  253 
Pustule,  121,  129 
Pyajmia,  96,  433,  437 

beginning  of,  in  thrombi,  433 

characteristic  changes  in  temperature,  435 

formation  of  metastatic  abscesses,  434, 436 

hemorrhagic  icterus  in,  436 

pathological  anatomy,  439 

prognosis  of,  438 

symptoms  and  diagnosis,  434 
Pyogenetic  membrane,  104,  255 
Pyogenic  micro-organisms,  125,  253 

lesions  produced  by  them  in  wounds,  271 

Questioning  of  patients,  502,  506 

Race,  influence  of,  upon  surgical  conditions, 

783 
Radiographic    localization   of   foreign   bodies, 
629 
plates,  method  of  examining  them,  641 
study  of  ossification,   579,  582,  598 
technique,  599 
tests,  612 

value  of  x-vsky  tubes  estimated  by  mil- 
liammeter,  616 
Radiographs,  interpretation  of,  640 

method  of  taking,   for  purpose  of  local- 
izing calculi,  628 
scheme  of  standards  used  in  Massachu- 
setts General  Hospital  in  taking  them, 
626 
Radiography   in    surgery,    general   considera- 
tions on,  599 


Raynaud's  disease,  a;-ray  appearances  of,  687 
Rectal  diseases  diagnosticated,  525 
Red  blood  cells,  importance  of  studying  them 
for  diagnosis,  557 
their  removal  and  changes,  260 
Red-cell  count  of  great  prognostic  importance 

in  surgery,  791 
Redness,  a  symptom  of  inflammation,  94 
Reflexes,  deep,  in  relation  to  diagnosis,  539 

superficial,  in  relation  to  diagnosis,  538,  539 
Reid,  William  W.,  49 
Regeneration,  256 

after  injury  of  peripheral  nerve,  289 
comparative  power  of,  in  different  tissues, 

257 
effected  by  cell  proliferation,  92 
factors  influencing  the  power  of,  256 
Renal  diseases  a  source  of  danger  in  adminis- 
tration of  ansesthetics,  785 
in  operations,  787 
Repair,  the  process  of,  92,  256,  259,  261 
Reparative  processes  as  they  differ  in  experi- 
mental and  complete  fractures,  282 
Resolution  of  inflammation,   98,  99,  259 
Respiratory'  acts,  changes  in  them,  and  their 
diagnostic  significance,  528 
organs,  diseases  of,  a  source  of  danger  in 

operations,  787 
system,  diagnostic  data  obtained  from,  527 
Rest  in  treatment  of  acute,  simple  inflamma- 
tion, 113 
in  treatment  of  wounds,  754 
"Rests"  as  related  to  neoplasms,  293 
Retractors,  748 

Retrograding  mouse  tumors,  the  immune  fac- 
tor in  the  blood,  400 
tumors,  action  of  3;-ray  and  radium,  402 
Rhabdomyoma,  embryonic  type  of,  316 
Rhabdomyo-sarcoma,  317 
Rhinoliths,  200 
Rickets,  677 

and  chondrodystrophia  foetalis,  .-r-ray  di- 
agnosis between,  676 
Riders'  bone,  315 
Risus  sardonisus  in  tetanus,  457 
Rodent  ulcer,  359 
Rodgers,  John  Kearney,  43,  44 
Roentgen  rays,   their  divergence  and  its  re- 
sults in 'photographs,  578 
Rubber  drainage  tubes,  740 

gloves,  their  use  and  care,  709 
tissue,  how  used,  741 
Rush  Medical  College,  of  Chicago,  founded,  27 

Saliva  as  a  source  of  infection,  699 

diagnostic  data  obtainable  from   its   ex- 
amination, 561 
Salt  solution,  normal  or  physiological,  704 


814 


INDEX. 


Salves  and  ointments,  759 
Sanies,  a  form  of  pus,  124 
Saprsemia,  96,  423,  425 

infection  with  proteus  vulgaris,  423 
Sarcomata  (atj^ical  meso-hylomata),  331,  333 
alveolar.  334,  336 
angiomatous,  338 
giant -celled,  335 
gross  appearances,  331 
in  rats,  transplantation  of,  391 
large  round-celled,  334 
meduUarj',  332 
melanotic,    spindle-celled    and    alveolar, 

341,  342 
mixed-celled,  335 
myeloid,  335 

of  definitely  organoid  type,  336 
of  mixed  type,  343 
perithelial,  338 
petrifjTing,  343 

presenting  peculiar  secondary  character- 
istics, 341 
resembling  carcinoma,  337 
small  round-celled.  333 
spindle-celled,  334 
teleangiectatic,  332 
tubular.  336 
where  developed,  331 
Ziegler's  classification  of,  333 
Sarcomatous  transformation  in  other  tumors, 

333 
Sayre,  Lewis  A.,  56 
Scab,  healing  under  a,  249 
Scar  tissue,  formation  of,  263 
Schools,    medical,    first    organization    of,    in 

America,  3 
Scissors,  744 

Scopolamine-morpliine  anaesthesia,  4S0 
Seaman,  Valentine,  13 
Seasoned  tube,  its  radiographic  value  indicated 

bj'  miUiammeter,  618 
Second  intention,  healing  by,  102,  268,  270 
Secondary  adhesion,  healing  bj-,  251,  252 
Secretion.?,  diagnostic  value  of,  561,  567 

from  the  female  genital  tract,   bacterial 
examination  of,  565 
Seminal   secretion,    diagnostic   data   obtained 

by  examination  of,  566 
Senn's    researches   on    the  ligation  of  blood- 
vessels, 725 
Sepsis,  its  surgical  meaning,  695 
Septicaemia,  96,  423 

asepsis  in  the  treatment  of,  441 
crj-ptogenetic,  430 
due  to  a  mixed  infection,  431 
etiology,  425 

free  drainage  and  irrigation  in  the  treat- 
ment of,  441 


Septicemia   from  general  peritonitis.  Pilcher's 
treatment  of,  442 
general  treatment  of,  442 
illustrative  cases,  428 
leucocytosis  in,  432 
post-mortem  appearances.  432 
primary-  prophylaxis  of,  440 
sj-mptoms  of,  426 
treatment  of,  440,  443 
Septico-pyaemia,  439 

as  a  result  of  diffuse  suppuration.  255 
Sequestra,  223 

their  persistence,  286 
Sero-fibrinous  catarrh,  116 
Sero-purulent  catarrh,  116 
Sero-pus  defined,  253 
Serous  effusion  in  inflammation.  116 
Serous  surfaces,  fibrinous  exudate  upon,  119 
Serum   or  agglutinative  reactions,   their  sur- 
gical diagnostic  value,  560 
Serum  therapy  in  septicaemia  and  pyjemia,  443 
Sex  as  bearing  on  diagnosis,  508 

relation  of,  to  surgical  prognosis.  777 
Shippen,  William,  Jr.,  7 
Shock,  463,  464 

alcoholism  in  relation  to.  4S3 

amputation  during,  486 

and  collapse,  differentiation  between,  491 

and  hemorrhage,  485 

arising  from  operations  on  the  kidney,  477 

arising  from  operations  on  the  testicle,  477 

as  caused  by  injury  of  the  different  organs, 

471,  476 
as  caused  by  injuri.-  of  the  different  tissues, 

470  '    ' 

as  caused  by  injury  of  the  joints.  470 
as  influenced  by  anaemia,  482 
as  influenced  by  jaundice,  484 
as  observed  in  operations  on  the  spinal 

column,  478 
as  related  to  asphjTiia,  472 
as  related  to  the  duration  of  the  operation, 

478 
blood-pressure  to  be  watched  as  an  index 

of,  490 
cardiac,  467 

Crile's  experimental  work  on,  468 
diabetes  as  related  to,  482 
diagnosis  of,  491 

effect  of,  upon  surgical  prognosis,  788 
emergenc}-,  494 
etiological  factors  in,  490 
from  acute  hemorrhagic  pancreatitis,  484 
from  rupture  of  abdominal  viscera,  485 
hemorrhage  an  element  in,  481 
Howell's  conclusions  in  regard  to.  467 
in  abdominal  operations.  475 
in  operations  involving  the  diaphragm,  475 


INDEX. 


815 


Shock,  in  operations  on  the  head,  471 

in  operations  on  the  neck,  472 

in  operations  on  the  spleen,  476 

in  operations  on  the  thorax,  473 

increased  by  exposure  to  cold,  488 

infants  less  Hable  to,  774 

influence   of   atmospheric    pressure   as    a 
factor,  288 

injuries  of  the  skin  in  relation  to,  469 

in  reference  to  auto-intoxication,  484 

nephritis  in  relation  to,  482 

operative  details  influencing,  469 

pain  as  bearing  on  the  production  of,  469 

possible  existence  of,  in  all  cases  of  trau- 
matic surgery,  488 

prognosis  of,  492 

psychic  factors  in,  488 

relation  of,  to  fall  in  blood  pressure,  465 

relation  of,  to  local  infections,  483 

relation  of,  to  starvation,  484 

relations  of  spinal  ansesthesia  to,  480 

salt  solution  in  treatment  of,  493,  494 

slight,  after  tracheotomy,  472 

symptoms  of,  492 

treatment  of,  493 

vascular,  467 
Shoulder-joint,  amputation  at,  59 

its  epiphyseal  development  as  shown  by 
radiograph}',  592 
Siderosis,  207 

Sight,  sense  of,  in  relation  to  diagnosis,  540 
Silicosis,  207 

Silk  as  used  for  sutures  and  ligatures,  725 
Silkworm  gut  as  material  for  sutures,  726 
Silver  wire  as  suture  material,  727 

in  gynaecologj',  57 

in  treatment  of  fractures,  728 
Sims,  J.  Marion,  57 
Sinkler's  reflex,  540 
Sinus  follo-n-ing  deep-seated  infection,  121,  255, 

419 
Skeleton,  living,  171 

Skill,  surgical,  how  it  can  be  acquired,  693 
Skin,  atrophy  of,  from  distention,  180 

from  pressure,  180 

neurotrophic,  180 

physiological,  179 
Skin-grafting  after  extensive  burns,  252 
Skin  sterilization,  702,  708 
Slough  or  moist  eschar,  252 

formation  of,  233 

in  open  wounds,  274 
Sloughing  or  phagedenic  ulcer,  229 
Smell,  sense  of,  its  importance  in  diagnosis,  541 
Smith,  Nathan.  21 
Smith,  Alban  G.,  15 
Smith,  Henry  H.,  19 
Smith,  Joseph  M.,  14 


Smith,  Xathan  R.,  24,  48 

Smith,  Stephen,  3 

Smyth,  A.  W.,  43 

Spinal  cord,  atrophic  diseases  of,  178 

complete  transverse  injury  of,  543 

complete  unilateral  injurj'  of,  543 

degeneration  of    (compression    myehtis), 
177 

partial  lesions  of,  543 
Spirochteta  pallida  to  be  sought  iij  supposed 

syphilitic  discharges,  566 
Spleen,  atrophy  of,  181 

in  leukaemia,  244 
Sponges  or  pads,  720 
Sputum,  diagnostic  importance  of  pathological 

findings  therein,  563,  564 
Staphylococci  and  their  effects,  417 
Stay  sutures,  752 
Steam  sterilizers,  714 

Stercorsemia  in  its  relation  to  surgical  prog- 
nosis, 790 
Stereoscopic  radiographs,  how  to  take  them, 

636 
Sterilization  of  catgut,  the  Claudius  or  iodine 
method  described,  731 

of  dressings,  713 

of  hands,  702 

of  instnmients,  711 

of  nail  brushes,  703 

of  skin  at  seat  of  operation,  703 

of  soap,  702 

of  sutures  and  ligatures,  724 

of  water,  apparatus  for,  712 
Stevens,  Alexander  H.,  14 
Stitch  abscesses,  753 
Stomach,  atrophy  of,  181 

cancer  of,  its  diagnostic  features.  519 

examination  of  and  diagnostic   informa- 
tion derived  from  it,  518,  520 
Stomach  contents,  their  examination  and  di- 
agnosis, 520,  521,  562,  563 
Stools,  diagnostic  examination  of,  525 
St.  Louis  Medical  College,  29 
Stone,  Warren,  28 
Streptococci  and  their  effects,  417 
Streptococcus  erysipelatis    and    Streptococcus 

pyogenes,  question  of  their  identity,  445 
Subclavian    artery,    left,    Kgation    of,    within 

the  scaleni,  43 
Subdiaphragmatic  abscess,  128 
Suppuration,  121,  250 

artificial,  in  the  treatment  of  pyaemia,  441 

circumscribed,  254 

conchtions  and  diseases  favoring.  126 

constitutional  infection  from,  127 

development  of,  122 

diffuse,  255 

forms  of,  254 


816 


INDEX. 


Suppuration,  results  of,  255 

when  involving  serous  membranes,   254 
Surgeon's  care  of  his  hands,  702 
Surgery,  American,  evolution  of,  3 

modern,  beginnings  of,  691 
Surgical  dressings  and  sponges,  71S 

procedures,  effect  of,    upon   the   diabetic 
process,  793 

technique,  essential  importance  of,  694 

treatment,  application  of  the  principles, 
750 
Suture  materials,  274 
Sutures  and  other  foreign  bodies,  274 

insoluble,  275 

soluble,  how  disposed  of,  275 
Suturing  of  intestinal  wounds;     histology  of 
the  healing  process,  276 

of  wounds;   tier  sutures  and  stay  sutures, 
752 
Sweat,  sterile  and  otherwise,  698 
Syndesmosis  defined,  284 
Synostosis  defined,  284 
SyphUis  a  cause  of  ulceration,  226 

not  a  bar  to  operative  measures,  792 
Syphilitic  disease,  x-ray  appearances  of  bone 

lesions  in,  663 
Sypliilitic  ulcers,  deep,  230 

superficial,  230 

Taste,  sense  of,  its  alterations  as  influencing 

diagnosis,  542 
Teeth,  diagnostic  data  supplied  by  them,  517 
Temperament,  influence  of,  upon  surgical  con- 
ditions, 781 
Temperature  of  the  body,  extreme  variations 
in  certain  diseases,  534 
in  relation  to  diagnosis,  533 
Tendons,  repair  of,  277,  278 
Teratoid   tumors   or  cysts,   simple   and   com- 
plex, 366,  367,  368 
Teratomata,  bigerminal  or  ectogenous;    foetus 
in  fcetu,  366 
malignant,  366,  368 

monogerminal,  endogenous  or  autochthon- 
ous, 366 
Wartliin's  classification  of,  367 
Testes,  atrophy  of,  181 
Tetanus,  453 

antitoxin,  its  employment,  460 
carbolic-acid  treatment  of,  461 
chronic,  458 
conveyance  of  the  toxins  to  the  central 

nervous  system,  454 
cryptogenetic,  453 
diagnosis  of,  459 
etiology,  453 
facialis,  459 
from  Fourth-of-July  gunshot  wounds,  454 


Tetanus,  local  treatment,  460 

neonatorum,  458 

pathology,  455 

prognosis  in,  459 

puerperaUs,  458 

symptoms,  455,  457 

traumatic,  453 

treatment,  459 
Thiersch  method  of  skin-grafting,  258 
Third  intention,  repair  by,  271 
Thoracic-duct     obstruction,    causing    pseudo- 
chylous ascites,  237 
Thorax,  inspection  of,  as  furnishing  diagnostic 

data,  514 
Thrombi,  healing  of,  105 
Thrombophlebitis  treated  by  ligature,  441 
Thrombus,  its  stages,  288 
Tier  sutures,  752 
Tissues,  reaction  of,  to  injury,  76 
Tongue,  its  diagnostic  indications,  517 
Touch,  sense  of,  in  relation  to  diagnosis,  535 
Towels,  as  used  in  operations,  720 
Toxic  ulceration,  from  drugs,  227 
Toxinsemia,  defined,  426 

in  inflammation,  96 
TrabeculiE,  their  development,  281 
Trained  nurse  and  her  duties,  722 
Training    school    for    nurses    inaugurated    in 

Bellevue  Hospital,  32 
Translucency  as  an  aid  in  diagnosis,  515 
Transplantable    mouse    tumors,    their    char- 
acteristics, 394 
Transudates,  237,  574 
Transylvania  University,  medical  department 

of,  founded,  25 
Traumatic    lesions    of   the    spinal    cord    from 

disease  or  injury,  their  effects,  544 
Tubercula  dolorosa,  319,  328 
Tuberculosis  of  bone,  x-ray  diagnosis  of,  644, 

645 
Tuberculous  ulceration,  226,  230 
Tubes,  radiographic  method  of  testing,  614 
Tumor  (or  neoplasm)  defined,  291,  292,  370 
Tumor  formation,  291 

arguments  against  Cohnheim's  theorj',  376 

as  related  to  unstable  cell  equilibrium,  293 

Cheyne's  views,  378 

Cohnheim's  theory,  374 

Kelling's  theory,  382 

Max  Borst's  views,  377 

results  of,  368 

Ribbert's  views,  377 

Schroeder  van  der  Kolk's  theory,  383 

hypothesis  of  parasitism,  380 

theories  of,  370 

Thiersch's  views,  378 
Tumors,  benign  and  malignant,  294 

classification  of.  294,  296 


INDEX. 


817 


Tumors,  etiology  of,  292 

gross  appearance  of,  293 

histioid  and  organoid,  295 

homoplastic  or  heteroplastic,  296 

in  mice,  their  contagiousness  and  com- 
municability,  393 

of  epiblastic  origin,  299 

of  epithelial  type,  344 

of  hypoblastic  origin,  299 

of  mesoblastic  origin,  299 

of  mixed  epithelial  and  connective-tissue 
types,  297 

of  non-epithelial  type,  301 

of  unstriped  muscle,  317 

spontaneously  retrograding,  their  his- 
tological characteristics  identical  with 
retrogression  effected  by  treatment,  401 

their  malignancy,  379 

ulceration  in,  227 

TJlceeatign,  210,  416 

and  caries,  223 

complications  and  sequelae  of,  232 

etiology,  224 

impaired  circulation  important  etiologi- 
caUy,  224 

in  glanders,  227 

in  leprosy,  227 

infection  an  element  of,  225 

pathology  of,  227 

phagedenic,  225 

pressure  a  cause,  225 

traumatism  a  common  cause,  224 
Ulcers,  131,  132,  41S 

annular,  142 

callous,  142 

croupous  or  diphtheritic,  142 

eczematous,  230 

fungating,  132 

gouty,  143,  230 

healing  of,  104,  132 

hemorrhagic,  132 

indolent,  132,  142 

irritable  or  painful,  143 

malignant,  131,  132 

microscopical  appearances  of,  228 

oedematous,  142 

perforating,  142 

phagedenic,  132 

pressure  (decubitus),  133 

raw,  142 

scirrhous,  132 

scorbutic,  230 

serpiginous,  132,  142 

sloughing,  132 

spreading,  132 

syphihtic,  131,  133,  143 

traumatic,  133 
VOL.  I. — 52 


Ulcers,  tuberculous,  144 

va:ricose,  133,  142 
Ulcus  elevatum  hypertrophicum,  142 
Ureters,    their    examination    and    diagnostic 

relations,  551 
Urethral   secretions,   data   obtainable   by  ex- 
amining them,  566 
Uric-acid  deposits  in  gout,  200 

infarcts  in  the  new-born,  200 
Urinary  calculi,  202 

chemical  classification  of,  202 

formation  of,  due  primarily  to  disturbed 

metabolism,  202 
of  cystin,  203 
Urinary  examination  for  diagnosis,  545 

to  determine  the  relative  activity  of  the 
two  kidneys,  568 
Urinary   organs,   relations   of  sundry  morbid 

phenomena,  552 
Urination,  diagnostic  features  of  modifications 
in  the  manner  and  frequency  of  the  act, 
546 
force  of  the  stream,  its  variations,  549 
Urine,  determination  of  urea  and  uric  acid  and 
deductions  therefrom,  568 
examination  of,  by  kiyoscopy,  568 
examination  of,  sources    of    error  to    be 

guarded  against,  567 
incontinence  of,  definition  of  the  term  and 

its  diagnostic  relations,  548 
overflow  of,  its  significance,  547 
retention  of;  causes  and  significance,  547 
Uterine  epithelium,  reproduction  of,  258 
Uterine    fibroids,    removal    of,    during    preg- 
nancy, 779 
types  of,  303 

Vaginal    secretions,    parasites    to    be    found 
therein,  566 

Van  Leyden's  bird's-eye  inclusions,  388 

Vascular  dilatation  and  paralysis  as  related  to 
shock,  465 

Vasomotor  paralysis,  diagnostic  features,  544 

Veins,  repair  of  injury  to,  288 

their  pathological  changes  as  related  to 
diagnosis,  531 

Veldt  sores,  230 

Venous  obstruction,  sequence  of  pathological 
changes  from,  235,  532 

Venous    pressure,    increased,    as    a    cause    of 
nedema,  237 

Vermiform    appendix,    perforative    inflamma- 
tion of;  report  by  R.  J.  Fitz,  59 

Von    Mosetig-Moorhoff   bone   plug,   its   prep- 
aration and  use   724 

Wallerian  degeneration,  178 
Warren,  John,  10 


818 


INDEX. 


Warren,  John  C,  19 

Warren,  Gen.  Joseph,  10 

Warthin,  Aldred  Scott,  71 

Warts,    significance    of   Perthes'    experiments 

with  the  x-ray  on,  402 
Wehnelt's  electrolytic  interrupter,  603 
Wehnelt  interrupter,  605 
Wells,  Horace,  6-t 
White  scar  tissue,   an  eligible  seat   for  skin 

grafts,  270 
Whitlow,  128 
Women,    greater    power    of      endurance     in, 

777 
Wood,  James  R.,  31 

Wounds,  accurate  closure  of,  its  importance  in 
treatment,  273 
aseptic,  surgical  principles  associated  with 

them,  751 
contused  and  lacerated,  756 
diphtheritis  of,  135 
infections  of,  415,  418,  757 
secondary  suturing  of,  757 
suspected,  755 
treatment  of,  272,  751,  758 

x-BAY  anatomy,  its  special  features,  642 
x-ray  appearances  of    subperiosteal    bone  de- 
posit compared  with  those  of   osteomyelitis 
and  periostitis  albumosa,  667 


x-ray  appearance  of  late  hereditary  and  ter- 
tiary bone  syphilis,  665 

of  diiTerent  types  of  osteomyelitis,  650 
x-ray  burns,  pathology  and  peculiarities  of,  638 
x-ray  exposure  as  a  cause  of  sterility,  637 
x-ray  plant,  essentials  of,  601 

importance  of  the  rheostat,  607 

the  coil,  its  essentials,  601 

the  interrupter,  603 

use  of  alternating  current  or  static  ma- 
chine, 608 
x-ray  plates,  compression  apparatus  used    in 
making,  description  of  it,  632 

development  of,  619 

method  of  taking  them,  625 
x-ray    therapy  in  cancerous  and  tuberculous 

disease,  600 
x-ray  tubes,  60S 

as  influenced  by  the  inverse  discharge,  611 

injurious  methods  of  using,  611 

methods  of  testing,  611 

phenomena    observed   in   the   process   of 
■  seasoning,  610 

the  cathode  stream,  609 

the  process  of  seasoning  or  ageing,  609 
x-rays,  harmful  effects  of,  636 

protective  measures  against,  639,  640 

ZUCKERGDSSLEBER,  140 


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